of tl}B ier0it? of il^ortb Carolina ti&otoeD bp ^^t ^Dialectic ano tai)iIant[)ropir ^otittits This hook must r he taken from t Lihrary huildin^. LUNC-15M N.36 OP-13370 Digitized by tine Internet Arclnive in 2010 witln funding from Nortln Carolina History of Health Digital Collection, an LSTA-funded NC ECHO digitization grant project http://www.archive.org/details/southernmedicine841922char Southern Medicine and Surgery Vol. LXXXIV CHARLOTTE, N. C, JANUARY, 1922 No. 1 SANITATION OF THE RURAL population of the United States live in HOMF* ^^ ^"^^^ section. As a general thing the rural home is constructed with no By H. L. Cook, xM.D., Fayetteville, N. c. regard to site, ventilation, exposure, The health of the country home de- character of soil, material, interior ar- pends in a large measure upon its sur- ""^^f T"L°'' drainage. roundings. It is a popular opinion that T^ building site should be so located, life in the rural districts is more health- ^^ ^^^.^^ possible, as to give protection ful than in the towns and cities. This ^^^J'^^t violent winds and storms; but would probably be true if the rural J'i"^h free circulation around the house. homes were governed by adequate sani- i- ^ tiwelhng house should be, not under tary laws, as is the case in most of the "' '^'^'""'' l^'^^ ^^^ ^^™ y^^^' cemetery, cities ; however, as a general rule the ^r' ^^J^'^^^ ^"^ preferably upon some rural dweller is inexperienced and ig- ^levated site. The material used in the norant of the cause and transmission of P^^ '^ ^ matter of the individual diseases and this disastrous condition ^"°^^^- is merely due to lack of education. It ^ proper system of ventilation must is believed that the results of educating ^^.^^, *"to consideration the cubic space those people along sanitary lines would ^^ ^'""^ building to be ventilated, the increase the sanitary status to a great '^""^ber of persons occupying that space, degree, and stamp out a large percent- certain other collateral elements, such age of diseases. as exposure, the necessity for artificial About one-half of the population of J^^^^^^^^ ^"d lighting of the house, and the United States are rural dwellers ^"^ ^^^^f°" °.^ *^^ ^^^^^ I" sleeping Very few have sanitary means of sew- H^^^^ the initial air space should never age disposal, and often no privy of any ^^ Jess than thirty-five (35) cubic kind is used. Usuallv the water supply '^''1%'''' ^°^ f " ^^^^^ <^?ho & Robins) is inadequate and does not meet the re- ^1"^ twenty-five (25) cubic meters for a quire ments of sanitation. Protection ^,^u "''n ^ ^^" ^'^^^^ °^ ^^^- ^" P^^^" from insects is nearlv always overlook- ^If^'?, all instances, natural ventilation ed, and to a great extent the entire home ^'^S^V ^"a does obtain in rural homes. is detrimental to health. The health of method of heating for the aver- the people in the rural districts affects ^^^^ ^"^'H ^^^ "^^^^ ^^^^ ^^ practical the health of the oeople in the towns t ^o^i^o^^ably inexpensive. In most and cities through association homes stoves and fire-places are found . in use; the fuel usually used is wood, Housing coal, or gas. When gas is used precau- The importance of house construction *^"" should be taken against leakage for the human being, in regard to hy- ^^°"^ fixtures and incomplete combus- giene and sanitation, is not sufficiently ^^°" ^^ the gas. Stoves should be prop- appreciated by the public. It is true ^rlv jacketed. When fire-places are that a great deal more importance is "^^d precaution against draughts should given to the building of dwelling houses ^^ taken. in the towns and cities than in the rural Protection From Insects districts ; however, this should not be, Insects are responsible for many pre- as probably more than one-half of the ventable diseases. The insect which *Read before the Sixty-eighth Annual Ses- most commonly transmit diseases are mosquitoes and the common house fly. sion of the Med.cal Society of the State of It is an established fact that the house North Carolina. Pmehurst, April 26-28, 1921. fly breeds mostly in stable manure; but, 2 SOUTHERN MEDICINE AND SURGERY January, 1922. also to to some extent in human excreta, to exclude the smallest disease bearing It is almost always found within a short mosquito; but large enough to permit distance of its breeding place. free circulation of air. The screen The diseases of mankind which may should fit tight both the doors and win- be transmitted by the human excreta dows. are typhoid fever, para-typhoid fever, Mosquito nets should be used in mos- the different tvpes of gastro-intestinal quito infested regions, but screenmg is diseases and tuberculosis. Of these ty- more important. Nets are easily blown phoid fever is responsible for approxi- aside by the wind giving free access to mately 40.000 deaths in the United the mosquito. States, with 400.000 cases annually. It Milk was proven during the Spanish-Ameri- Clean milk is absolutely essential to can war that with an increase in the health. The degree of cleanliness of number of flies there was a correspond- milk is controlled by the cleanliness of ing increase in the number of typhoid the dairy and its surroundings, and the fever cases. cleanliness of the milker ; also, much Without adequate screening of the depends upon the dairy herd, homes the house fly will be free to feed The diseases commonly spread alterrately from excreta, putrefying through milk are tuberculosis, typhoid animal and decaying vegetable matter, fever, diphtheria, sore throats and sum- as well as from the dining table and mer diarrhoea. kitchen, bringing filth upon their legs. Very few milch cows, especially those within and on their bodies from these owned by the rural dweller, are subject- various places and depositing upon the ed to the tuberculin test. It is now be- food : contaminating it with organisms lieved by many medical men that a vast found in these various places. amount of human tuberculosis is con- It has long been known that mosqui- tracted in infancy by drinking the milk toes are carriers of diseases. Of these from tuberculosis cows. diseases I will only mention those that Typhoid fever is often transmitted by are most commonly seen in the United means of milk. The milker may be a States and can be prevented. There is carrier. Often the house fly has free a certain type of mosquito that carries access to the privy and milk supply, in the organism of malaria fever, which is this way, the milk becomes contamin- by far the most common disease in the ated with the bacillus typhosis, if the Southern part of the United States ; an- organism happens to be in the privy other species of mosquito carries the or- contents. Many other organisms may ganism of yellow fever which is seen be deposited in the milk supply, from mostly in the tropical regions. this same source, which cause the fatal As a measure to prevent these mos- diseases in fancy, i. e., iliocolitis, or quito born diseases, we must rid our- summer complaint. This disease alone selves of the mosquito, destroy the or- causes forty p.er cent of mortality ganism of the disease in man as far as among infants under one year of age. possible and protect ourselves by Inflammatory diseases of the udder are screens. All low places should be filled responsible for numerous cases of sore or drained, standing water should be throat. drained, or the surface water covered Milk forms an excellent medium for with kerosene oil once a week. All tall the growth of germs, therefore the best weeds and underbrush should be cut way to obtain clean milk is by proper down. Cans and other receptacles that care of the dairy herd, such as cleanli- contain water should be disposed of, un- ness of the barn and surroundings, clean less used for some special purpose, and milk cans and screening the dairy from these should be securely covered. Per- flies. The milker must be of clean hab- sons suffering from any mosquito born its and free from infectious diseases, disease should not be exposed to mos- Cows should undergo the tuberculin quitoes ; this end can only be obtained test, and those that react should be dis- by proper screening of the home. carded. A clean, well lighted and ven- In screening a house, care should be tilated barn is necessary, taken in the selection of the screen. In warm weather the milk should be The frame should be heavy enough not placed imxnediately after milking in a to warp and of lasting material. The refrigerator, or in a well stopped and size of the mesh should be small enough covered container and placed in a cool January, 1922. ORIGINAL COMMUNICATIONS Stream of water, which is protected deep water supply, driven or bored well against contamination. with close fitting, water tight, tile or Water Supply ^^o" casing, well protected at the sur- It is a well known fact that water face by concrete platform, and located transmits many of the germ diseases f J^^^ distance (at least 200 feet) from ■ - - "^^^ ^^ -" "^ " It should be the modern such as typhoid fever and gastro-intes- tinal complaints. The sources of water are classed as surface and shallow and deep under- ground supplies. The surface supplies are obtained from ponds, streams, reser- voirs and cisterns. The shallow and the privy and barnyard equipped with one of pumps. Sewage Disposal Directly and indirectly excreta of hu man beings are responsible for most all preventable diseases ; therefore, it is the deep underground supplies are from demand of sanitary science that proper springs and wells. care should be taken in the construction Water obtained from surface supplies and operation of sanitary sewage dis- are usually polluted and should not be posal systems. The system to be used used for drinking purposes, unless pro- tected from contamination and purified before using. The underground supply is generally clas.sed as deep and shallow. Wells un- der 30 feet in depth are considered shal- low supplies. Very little thought depends to a large extent on the finan- cial status of the home. For this reason the system to be recommended should conform to the financial status of each individual home: and at the same time answer the requirements of sanitary is science. These requirements should be given, in a large per cent of cases, to inexpensive, convenient, fly proof, well the location of the well. On some farm ventilated, water tight and easily oper- homes the;y' are located near the privy, ated. while others are in the barnyard or The woods, stalls, barns and open-in- stock pen. where the location invites back surface privy and usually the pit pollution. privy as sewage disposal systems are a Ihe sinking of a well, as regards to menace to human life, and where these sate y from pollution depends upon the systems are found, there are always ocation the method and the type of found typhoid fever and the diflTerent the sinking, the character of the soil, gastro-intestinal diseases. oJ'draTnage P'"*''''"" ""^' '^' ^""^^^^^" The vault privy, unless well construct- rp. ^ , „ ■ „ . J . , , ^^' ^^ ^^ dangerous as a surface privy Ihe u ells generally found at the farm and will perhaps claim as many victims. houses are dug with very little protec- The "A" type sanitary pail privy rec- tion trom surface poi.ution and are ommended by the United States Public usually of the shallow arrangement. Health Service for This kind of well is especially when it is privy supply i.v lution ,, , . .,_ unsewered districts usually polluted, (Public Health Bulletin No. 684) com.- located near the plies with all the requirements of sani- in any. or barnyard. When the water tary privy. It can be placed possible source of pol- house, is inexpensive, easily operated, a great deal of care should be fly proof, water tight, well ventilated, taken in the curbing and casing of the and convenient. The essentials of this well. If this IS made water tight the privy consists of a fly proof box, self- surtace water will have to sink through closing holes, a flue which reaches about the ditterent strata whether sandy or twelve inches above the house and a me- clay soil, and is thus filtered and most tallic water tight can for the reception ot the constituents of pollution removed, of the excreta Springs usually receive their supply The cement' vault sanitary privy is trom the deeper strata, and are not pol- more expensive in the beginning, but is except at their out cropping ; much cheaper in the long run, because It care is taken to prevent the cost of operation is not as much as luted therefore pollution at the surface, spring water is usually safe for human consumption. The spring should be well drained, cased in and covered. the pail type, and the construction is more permanent. The excreta from the pail system and R„ *„„ 4.U u ^ . *^^ cement vault should be removed n ho ^Kfo- ^^? ^^^^^, l"PP^^ ^^^^ ^^^^ distance from the water supply 1- ^^j buried in the active layers of the can be obtained for rural homes is a 4 SOUTHERN MEDICINE AND SURGERY January, 1922 soil, to a depth of about fifteen to eight- EMPYEMA* een inches. The septic tank system has its ad- By James W. Davis, M.D., and vantages and disadvantages. It is ex- pj-ed c. Hubbard, M.D., pensive in that adequate plumbing with Statesville N. C. water pipes are necessary. It should ' not be used in thickly populated sec- The frequency of empyema of the tions with shallow wells and with a clay thorax, especially during the winter and soil. early spring months, and the necessity Garbage for early recognition and the institution Garb-ge scattered over the yard will of proper treatment, make it one of the attract and serve as a breeding place most important conditions with which for the house fly. A receptacle should we have to deal. be p-'ovi'ed to receive all refuse from Suppurative conditions within the the kiichen. The receptacle should be thorax may follow mild lung and pleural screened from flies, and made of fly infection as well as the more severe proof material so that the refuse can pneumonias and may even be secondary be burned from time to time. Refuse to focal infections in more distant parts that won't burn, such as tin cans, bro- of the body. A suppurative appendicitis ken china and glass-ware, should be car- or a furuncle on a finger may cause em- ried some distance from the house and pyema. buried or dumped on some vacant or since the epidemic of influenza in uncultivated land. 1918^ empyema has been more frequent The dish-water, slops and vegetable than usual. All ages are affected. Our refuse of the kitchen can be disposed of patients during the past year have at the hog-pen, or else carried some dis- ranged from 41/2 to 64 years, of age. tarce from the house at frequent inter- Pleural effusions and^ collections of vals and the container emptied. Pus may be free in the pleural cavity or Manure should not be allowed to ac- may be encapsulated and vary in quan- «„v,^„i„+^ ,•„ ^-u^ ^14- u + tity from an ounce or two to a gallon or c imulate m the cow lots or horse sta- ^^^^ ^he smaller collections of pus bles. The manure should be thrown between the lobes of the lungs or where out in the sunshine each day, or kept in the collection is encapsulated in some a fly-tight and water-tight bin and haul- portion of the pleural cavity are more ed once a week and scattered out in the difficult to locate. Only by means of ^ 1 J careful X-ray examination is it possible ■ . , <, , , . 1 , to diagnose some of these empyemas. The idea of this paper has been to After a careful physical and X-ray ex- present sanitary measures that are amination, an aspirative needle will aid practical and applicable for the average greatly in clearing up a doubtful diag- rural home. Many of the measures "^s^^- ^ 10 c.c. Luer syringe and a 24- above outlined have been advocated by P"/^ T^^^ °*" .the proper length will 4^1, r> ^^■ tt li^i o • • •, •, be found Very Suitable for this purposc. the Public Health Service in its sanitary The use of a weak solution of local an- surveys of the various counties of the esthetic to infiltrate the tissues will be United States. Those counties which helpful and in case a larger needle is have enjoyed the benefits of the sani- inserted at the same location for the tary survey have not only shown a "^"^''"^T ""^ ^f^'f^'""^' ^j," ^^^^ ^^^ f^^ , ■, J ^. . ^,,, , ,. already anesthetized and save any fur- marked reduction in filth born diseases, ther delay. Only after determining the but also reduction m other diseases. type of fluid present and taking into consideration the general condition of the patient should treatment be begun. For the modern treatment of empye- The next annual meeting of the Tri- ma, we owe much to the former sur- S;ate Medical Association will be held ^^^"^ ^^ ^^e United States Army, whose February 22-23, 1922, at Norfolk, Va., careful study and observation on which with headquarters at the Monticello *Read before the Ninth District Medical So- Hotel. ciety, Salisbury, N. C, October 28, 1921. January, 1922. ORIGINAL COMMUNICATIONS the present treatment is based aided so much in reducing the mortality and has- tening the recovery. When a patient is in the active stages of pneumonia and an empyema is form- ing only aspiration is indicated. Resec- made tion of a piece of rib and drainage in the presence of an aciive pneumonia ary disease and the associated toxemia and general cated. weakness of the patient would only give a high mortality. Empyema is usually due to the rup- ture into the pleural cavity of a sub- cortical lung ab.^cess. A large pleural exudate forms and if, in this stage, a thoracotomy is done the inrush of air following the sudden removal of the fluid cases a collapse of the lung and a fluttering of tne medistinum. the wall of which is not yet infiltrated and the action of the already weakened heart is greatly depressed, and a mortality may result. If thoracotomy is delayed until the acute stages of the pneumonia is past, the general condition of the patient is improved; by this time the seropurulent fluid is purulent and adhesions have Conclusions 1. Whenever possible, a careful X- ray examination in addition to the physical, supplemented by aspirations, to determine tne type of fluid, should be :le. >'. In the presence of active pulmon- only aspirations are indi- 3. Drainage should be instituted only after an empyema is encapsulated and the patient's general condition has im- proved. 4. nigh pro;;ein feeding is necessary to combat the weakening effects of the enormous drainage and to hasten re- cover v. MODERN OBSTETRICS Pierce Rucker, M.D., Richmond. V; When Marie de Medeci was to be con- fined for the first time, her royal spouse, Henry IV of F'rance, not only engaged the best known midwife of all time, Louise Bourgeoise. but also retained . , Guillemeau, a pupil of Ambrose Pare, in formed encapsulating the empyema and case there should be any complications the mediastinum is infiltrated so that This precaution proved to be unneces- evacuation of the pus and drainage will sary, and the future Louis XIII entered not cause the danger and distress that this world spontaneously amid great would result if done earlier. pomp and ceremonv, although the poor It is not the purpose of this paper to mother discuss in detail the surgical treatment Several of empyema except to state that simple resection of a piece of rib under local anesthesia, at the most dependent part of the empyema with simple drainage and high protein feeding to combat the general weakness of the patient from the constant drainage, gives excellent results. In some cases a general an- esthetic may be necessary. The Carrell-Dakin method of treat- ment in cases in which there is no pleu- ro-pulmonary fistula gives excellent re- sults. In certain cases the closed meth- od of draining the empyema cavity is very useful, and can be easily combined had a long, te lous time of it. times the queen seemed com- pletely exhausted and was at the point of giving up in despair, but was kept at work by the exhortations of the famous midwife. This was in 1601 when mid- wives were in universal use, except in the most complicated cases. As late as 1762 a xMrs. Stevens officiated when George IV of England was born, while the celebrated John Hunter waited in an anteroom to take care of any com- plication. More than a hundred and fifty years have elapsed and we snll cling to this dual standard of obstetrics. It is true that the physician has largely supplant- „,,>u ^.u^ ^^r.„„ • • .., ,, 6f^ ^^^ midwife except in confinements .T. .«. u ..!^^ °" exercises with the among the very poor. The practice, Wolff bottles. however, remains the same, is a When the Where more than one pocket has ^^^^ ^^ ^ "normal" one, he does little formed care must be taken to evacuate "^°^'^ ^^^^ ^^^ midwife of the middle these. An X-ray examination is of great value in following the course of recovery and in determining the final results. ages. Only the abnormal mother re- ceives the benefits of the best obstetric =-=Read before the Fourth District Medical Society at Goldsboro. August 9, 1921. 6 SOUTHERN MEDICINE AND SURGERY January, 1922. knowledge and practice. Even our hos- seventh month of pregnancy to the pital nomenclature is an evidence of this third week post-partum) of 7 per cent, fact. If the mother toughs it out for Holt and Babbitt' in a similar series at thirty-six hours or more and delivers the Manhattan Maternity found an in- herself spontaneously, it matters not if fant mortality of 9.73 per cent, and the child be stillborn and the perineum Moran' in Washington a mortality of deeply lacerated, the case is classed as a 12.72 per cent. In Richmond in 1918 normal one. On the other hand, if a and 1919 the still births and infant humane accoucheur interferes at the deaths under two weeks amounted to end of the first stage, and delivers her 11 per cent. The commoner causes of by version or forceps of an undamaged death in Williams' cases were as fol- child and without laceration, we call it lows : syphilis, 26.4 per cent ; unknown, an abnormal birth. 18 per cent; dystocia, 17.6 per cent; va- Our vital statistics offer incontro- rious accidental complications such as vertable evidence that present day prolapsed cord, 11.2 per cent. More re- methods are wrong. From the records cent studies by Warrick, Bailey" and of the census office it is estimated that others show that from 40 to 50 per cent 20,000 women lose their lives each year of new born infants coming to autopsy in the United States from this "physio- have intracranial hemorrhage. If we logical" phenomenon. Although it is look at this question squarely and hon- more than sixty years since Oliver Wen- estly, we see that in this day of enlight- dell Holmes and Ignatz Philip Semmel- enment we are losing one mother out of weis proved the contagiousness of puer- 134 and about one baby out of ten. If peral fever, and put the practice of mid- such a mortality attended some surgical wifery upon a sound modern basis, still procedure, would the surgeon be corn- one' woman dies in every 134 confine- placently content with his technique? ments in the registration area and one The first step necessary for the solu- in every 127 in North Carolina (14). At tion of our problem is to disimbue our times the death rate is even higher. For minds that parturition is a physiologi- instance, in Richmond' in 1920 there cal process. We should do away with was one maternal death in every 84 la- such terms as "normal labor" and bors (one in 42 colored and one in 129 should study every case as thoroughly white). The records show that more as we do our typhoids or gastric ulcers, than 40 per cent of puerperal deaths Dr. Potter'" in Buffalo delivers practi- are due to sepsis, approximately one- cally all of his cases at the end of the half of the remainder are due to hem- first stage by version. His record last orrhage, and one-half of the balance year was 1,113 deliveries, of which 920 (12.5 per cent) are due to toxemia, were versions. He tells me that he three conditions that are more easily started doing versions as a routine in prevented than is typhoid fever. the following way : Buffalo has a large Julius Levy* has shown by the rec- foreign population and consequently a ords of the Newark Health Department large number of midwives. Potter de- that mortality among midwife cases is veloped his technique in helping the practically the same as that in the cases midwives out of their difficulties, and attended by physicians. He was of he soon noticed that he was getting bet- course careful to charge back to the ter results with these difficult cases midwives all the fatalities that occurred than he was by waiting on the "normal" in the cases that started under their ones. care. That trained physicians should The day of haphazard methods has make as bad a record on the books of passed. The ideal obstetrician should the health department as ignorant mid- be a skilled diagnostician, a sensible wives proves, to my mind, that there is therapeutist, an endocrinologist, and ex- something more to obstetrics than sur- perienced hygienist, and a clean sur- gical cleanliness. geon. He should see his patients early The record from the standpoint of in their pregnancy. His examination at the mother is black enough, but if we that time should include a careful his- consider the neonatal mortality, we, tory, not only in the usual medical with our present day methods, have sense, but also in special reference to even less to be proud of. Williams' in previous pregnancies and labors ; a com- a study of 10,000 births at Johns Hop- plete physical examination of head, kins had an infant mortality (from the chest, abdomen, and pelvis ; a Wasser- Januarj', 1922. ORIGINAL COMMUNICATIONS mann test ; and any other special exam- inations that may be indicated. After making a complete inventory of the pa- tient's assets and liabilities, he should use everv effort to correct all defects as early as possible. Especially is this im- portant in regard to the teeth, the ton- sils and the appendix. The treatment of nausea and vomiting is his especial province at this time, and with the new endocrine remedies, he can relieve un- necessary suffering and avoid the need- less sacrifice of fetal life, patient is in the best of health, her physician should see her at least a month and should keep an accurate record of her weight, blood pressure, and urinary findings. At these visits it is well to inquire particularly for such of labor, etc. After a general anesthetic the uterus should be kept contracted by mechanical stimulation until pituitrin or ergot takes effect. In this connec- tion it IS well to bear in mind that while pituitrin is quick in acting, its action is of short duration, and it is often nec- essary to bolster it up with ergot. A third factor that is a very potent one in the causation of morbidity, and at times even of mortality, is laceration of the birth canal. In regard to its pre- Even if the vention, the most important thing is the complete relaxation of the pelvic twice muscles with a general anesthetic. It is the rule nowadays to repair all lac- erations when they occur. In addition to this I understand that at Johns Hop- kins they now take at least one stitch in every perineum to catch up and sup- port any muscle_ fibers that may be torn proce- subse- symptoms as headache, constipation, edema, pains in the abdomen and back. and spots before the face. In this way submucouslv. I believe such a you impress upon the patient the im- dure will .save you an occasional portance of these danger signs. You quent surprise, do not have to instruct her about bleed- ing as a danger signal, as she will nat- urally report that at once. Dr. Charles Reed," of Chicago, has written a great deal about the dangers -• Careful su- of postmaturity. Not onlv is the naril pervision not only insures against the to the child definitely enhanced by go- ing past the usual time for delivery, but usual complications of pregnancy, but gains the patient's confidence, and she approaches labor in a much better con- dition both physically and mentallv. Reports from Boston" show that prenatal care reduces the number of still births by one-half, and the number of infant deaths by two-thirds. My own experience at the Dispensary of the Medical College of Virginia leads me to believe that such a statement is no ex- aggeration. the mother runs gre iter risk from a more difficult labor; postpartum hem- orrhage, and perineal lacerations. Re- uch cently a case came under my observa- tion that well illustrates these dangers. The patient was a colored woman, nineteen years of age, who was preg- nant for the first time. She came to the Medical College Dispensary on February 2, 1921, where it was determined that she had a funnel palvi.' Ti'. , . , ' ■■- " .......^. ^cui.^, the transverse When you have carried your patient diameter being 6.75 cm. Her urine and sately through her pregnancy, the prob- blood Wassermann were negative. The lem ceases to be one ot preventive med- patient refused hospital treatment and icine, and becomes a surgical one. I did not return to the dispensary. On need not emphasize to this audience the February 23rd, she b3gan to have con- importance ot clean surgery. There are vulsions. The students were called af- other factors however, that are not so ter the second convulsion. She was T i^'^T.^u^'l^^'^- T^^ ^^'"^ «^ ^^^^^ '^ ^i^-e" morphine and her stomach and shock \^ hatever that may be, no sur- bowels were washed out thoroughly geon likes to operate upon a patient who The morphine was continued until the has been exhausted by suffering. It convulsions were controlled. At 9 a m seems to me that we should apply the five hours after the treatment was be- lessons the general surgeon has learned gun, the patient was left in charge of about the harmfulness of pain, to the a negro woman with instructions to call special field of obstetrics. Hand in hand the hospital if the patient became rest- with pain goes hemorrhage as a factor less. In the late afternoon the patient in tavoring infection. Every effort again began to have convulsions, and a should be used to avoid the things that few hours later was seen by the student lavor this, such as exhaustion of the as he was making his routine call The uterine muscle, cervical tears, the im- patient was brought into St Phillips proper management of the third stage Hospital comatose with a temperature 8 SOUTHERN MEDICINE AND SURGERY January, 1»22. of 102. The next morning (February off the parts with 1-2000 bichloride so- 24th) the head appeared at the vulva, lution. A large bivalve speculum lubri- and as it made no further progress, was cated with tincture of green soap is in- delivered with forceps without anesthe- troduced and the cervix exposed. This sia. This was the first time that there is swabbed with 50 per cent tincture of had been any vaginal examinations. The iodine and alcohol, and the speculum baby was macerated, and I was unable and then the swab withdrawn. The cer- to deliver the shoulders until I did a vix is nearly always soft and will admit double cleidotomy, and even then I one or two fingers. If necessary it broke the neck and stretched it out so should be dilated to this extent. A No. that it measured 11 cm. The infant 5 Voorhees bag can then be placed weighed nine pounds and measured 63 within the cervix with ease. I prefer cm. The mother died February 26th of a No. 5 bag, because when it escapes pneumonia. Had this patient been de- from the cervix, dilatation is sufficient. livered when she came to the dispen- Sometimes, when I have used the No. 4 sary, the eclampsia, pneumonia and bag and completed the dilatation man- possibly the fetal death would have been ually, the cervix has clamped down on avoided. the head and I have had to peel it over Of course, one case is no proof one the head with my hand introduced be- way or the other, but if you will run tween the head and the posterior lip of over in your mind the cases with which the cervix. This has not been neces- you have had the most trouble and have sary with a No. 5 bag. On the other gotten the worst results, you will find hand, the No. 6 bag is so large that un- that most of them have been women less the pelvis is a justo-major one, it who have gone over their time and have rests upon the brim of the pelvis and is babies measuring 54 cm. or more in slow in stimulating labor pains. length. A second or third dose of hyoscin may Our surgical problem then resolves it- be given, but the morphine is not re- self into cleanliness, the avoidance of peated. The hyoscin not only makes the unnecessary suffering and hemorrhage, first stage more comfortable, but it also and the minimizing of trauma. Just shortens this stage by favoring dilata- what methods one should use depends tion. The progress of labor is followed in a measure upon the operator, and by rectal examinations. The dilatation upon the individual patient. DeLee" is takes from two to twenty-four hours, using as a more or less routine what he It is usually completed within nine calls prophylactic forceps, or forceps at hours from the time the bag is placed. the end of the first stage of labor. Pot- The bag is now deflated and removed ter believes that version is best suited from the vagina, and, with the patient to the average case. For the past two relaxed with an anesthetic, a version is years I have been doing podalic version done after the method described by Pot- according to Potter's technique, and ter. with increasing experience (which now By this combination of the induction amounts to more than 330 cases) I am of labor as advocated by Reed and ver- more firmly impressed with its value, sion as described by Potter, you avoid More recently I have adopted Reed's all the more common dangers of child method of managing the first stage of bearing. In the first place, you cut the labor, and I find that it is a distinct ad- duration of labor down at least one-half, vantage in doing the version. On a suit- and the suffering incident thereto to able day, approximately at term, as de- the barest minimum. The mothers are termined by the history and checked up not shocked and show none of the signs by fetal measurements, the patient of exhaustion so common after a pro- comes to the hospital and is prepared longed labor. The integrity of the birth for delivery. There is no hurry and ex- canal is preserved in a manner I have citement, and no worry as to whether never been able to do until I began do- the doctor and the nurses will be ready ing the Potter version. Immediately for her. Morphine, grains 1/6, and after delivery, while the patient is still hyoscin, grains 1/100, are given an hour under the anesthetic, there is a tendency ahead of the time appointed for bag- to bleed, that must be guarded against ging her. When the patient is on the by mechanical stimulation of the fundus table I again scrub her up with tincture until a hypodermic of pituitrin or ergo- of green soap and sterile water and rinse tol takes effect. The uterine muscle is January, 1922 ORIGINAL COMMUNICATIONS 9 not fagged out and there is no danger Clinical support of these findings was of secondary hemorrhage. The chances first brought to my attention by the of sepsis are materially lessened by the nursery nurses, who noticed that the clean surgical technique the shortening version babies sleep most of time and do of labor and diminished suffering. The not fret unless they are hungry. In dangers to the mother and child of post- other words, they behave like well-fed maturity are avoided, and there is no little animals. They grow off well and danger of a prelapsed cord. After a lit- when they go home the family are en- tle experience with Potter's method of thusiastic over their behavior. This is doing a version you no longer worry especially so if the mother has had about the possibility of a faulty position other babies with which to compare the of the child, and expertness in placing new arrival. The explanation of this bags robs placenta previa of its terrors, clinical fact — and it has been told me In short, all the calamities that may so often without any suggestion on my befall a woman in labor, provided she part, that I am convinced that it is a is normal and the fetus not deformed, clinical fact — is I believe the absence of are avoided by forestalling them, cerebral trauma. Finally, the chances for a subdural Conclusions hemorrhage are very greatly lessened. o^. • ^- i • , The baby's head is spared the stress and Statistics prove conclusively that strain of even an ordinary delivery. present day obstetrics are not ideal. That such is the case 'is well shown ^^a^^ patient should be thoroughly by necropsy findings. In the two years studied in the early part of her preg- that I have been doing the Potter ver- "^"9'-. ^"^ ^^.?^\'^ ^^ ""^^^r careful su- sion twentv babies have come to au- Pervision until she is delivered, topsy. Threeofthe.se had markedlv . Every patient should be individual- enlarged thvmuses, one had a well ized and should be delivered by the marked endocarditis, two had broncho- method that best suits her case, due re- pneumonia, and two had subdural hem- S^^^^ ^^mg paid to conserving her orrhage. The remainder were entirely strength and resistance, negative. Three of them were post- I", ^^f^' ^^ t^e prevalence of mtra- mature and four were premature, labor cranial hemorrhages in babies dying at being induced on account of toxemia of ^^ shortly after birth, and the possibil- the mother. One was born of an eclamp- ^^^ "^ serious nervous disturbances in tic, and two had large red infarcts of ^^^er life should the baby survive, every the placenta. One of the two cases of effort should be used to avoid all pre- intracranial hemorrhage was delivered (disposing causes ot this condition, prematurely on account of placenta References previa. Labor was induced by a No. 4 i. Allport, W. H.: Am. J. Obst., LXV, 820- bag. When the cervix was nearly fully 851, 1912. dilated V-i C.C. of pituitrin was injected 2. U. S. Census Report for 1920. intramuscularly. This caused marked 3. Annual Report of the Richmond Health tetanic contraction of the uterus, but Bureau for 1920. the fetus was not expelled. The deliv- 4. Levy, Julius: Am. J. Obst., LXXVII, 41, ery was accomplished by version. I be- Jan., 1918. lieve that the pituitrin was partially, at 5. Williams, J. Whitridge: J. A. M. A., least, responsible for the hemorrhage, LXVI, 95, Jan. 9, 1915. as it has been noted by a number of 6. Holt, L. Emmett, and Babbett, Ellen C: observers that pituitary extract has J. A. M. A., LXIV, 287, Jan. 23, 1915. such an action. The second case was 7. Moran, John F.: J. A. M. A., LXV, 2224, that of a funnel pelvis. I had planned Dec. 23. 1915. to do a forceps operation but when a 8. Warrick, Margaret: Am. J. Med. Sc, hand prolapsed, version offered the only CLVIII, 95, July, 1919. chance for the child. The head had to 9. Bailey, Harold: Am. J. Obst. and Gynec, be forced through the pelvis with a L 52, Oct., 1920. great deal of force. Even with the un- 10. Potter, Irving W.: Am. J. Obst., favorable cases included, I have an in- LXXVII, 120, Feb., 1918; Am. J. Obst. and cidence of only 10 per cent which com- Gynec, 1, 560, March, 1921. pares very favorably with percentages H. Emmons, Arthur B., 2nd: Transactions obtained by Bailey, Wai'wick, Spencer, of the Fifth Annual Meeting Am. Assn. for and others (40 per cent to 53 per cent), study and Prevention of Infant Mortality, 10 SOUTHERN MEDICINE AND SURGERY January, 1922. 1914; Boston Med. and Surg. J., CLXXII, 618. 640, Apr., 1915; CLXXII, 690, May, 1915. 11. Putnum, Mrs. William Lowell: The Sur- vey, Jan. 4, 1913. Annual Report to the Am. Assn. for Study and Prevention of Infant Mor- tality, Nov., 1914. Printed in the Bulletin for Dec, 1914, of the Women's Municipal League of Boston. 12. R(M'(], Charles P.: Sui-g., (iynoc. and Obst., XXII, 294; XXV, 201; XXVII, 163,23 K 13. DeLee, J. B.: Am. J. Obst. and Gynec, I, 34, Oct., 1920. 14. Myers, Katherine. R. N.: Southern Medicine and Surgery, LXXXIII, 329, July, 1921. THE ECONOMIC PROBLEM OF THE DOCTOR By Drs. D. W. and Ernest S. Bulluck and R. H. Davis, Wilmington, N. C. The solution of the financial difficul- ties of the practicing physician has of- ten been attempted. It seems to us that the advice usually given is impractical and frequently its application is impos- sible. These economists maintain that the doctor is highly trained, works hard, is worth more than he gets and that he should charge more for his services and thereby improve his financial condition. As a class the physician fails to be- come independent in old age, and too large a number of them become depend- ent upon the bounty of relatives or the charity of friends. Here certainly is a problem that deserves some of the time and thought they so lavishly bestow upon their patients. To increase his income by larger fees is not the solution of his problem. He always has, and may be trusted to charge all "that the traffic will bear." Some men who are thorough and who have attained a reputation for being so may command large fees, but they in- crease the scope of their investigations and limit the number of their patients. While their scientific zeal is satisfied, their financial condition is but little im- proved. Only few men can maintain such practices, for there are relatively few discriminating patients who desire complete investigation of their ailments. The majority prefer superficial exami- nations and haphazard medication, at a small charge, relying upon expert con- sultation or further investigation, only after the primary treatment has failed. Such patients will be encountered more frequently because large wars are fol- lowed by years of retrenchment and fru- gality. People with trivial ailments and minor discomforts will call on the doc- tor less often. No matter what fees he may charge, he will see fewer patients, and they will have less money to offer for his services. It seems to us that for .years the income of the doctor will progressively diminish. The lives of our medical celebrities, men capable of demanding proper remuneration, con- vinces us that for the average practi- tioner who confines himself to the lim- its of his profession, there is the com- fort that comes from conscientious ef- fort, a good living while he works — and very little more. So far as we can learn, physicians who have succeeded financially and who have built up personal estates, have not been those men who were most skilled and who treated the wealthy or the aristocratic. They have been the phy- sicians of unimportant salaried people. These men diagnose clinically, treat empirically, do the best they can under the circumstances, and pass on to the next case. They have all used the same formula for the attainment of wealth. They five on less than they make and invest the difference, the size of the es- tate depending upon the size of "the difference" and the capacity for invest- ment. Any physician who does not real- ize this simple requirement and conduct his business to conform with it, can be assured of ultimate poverty and de- pendencJ^ Even then one must begin early, for "the difference" is so small, that it takes a life of accumulation to become independent before infirmity and competition forces him into retire- ment. Physicians have usually made the same investment — land, a farm in the country and improved real estate in the city. They have been uniformly suc- cessful and the reason for this is shown in Charts Nos. 1 and 2. In 1897 com- modities and real estate prices started upward and continued to climb for 23 years, the peak of the movement being reached in 1920. Real estate purchased at a fair market value at any time dur- ing this period would have enhanced in value every year. Suppose now that the physician adheres to the same type of investment. What are the chances for profit? Referring to Chart No. 1, January, 1922. ORIGINAL COMMUNICATIONS 11 -1 """"""r::::::::E ^ u f^-^ *- ^^Ty^r^^ J. I ', J •■ i '■ -w h *■-*— 1 if 4 i -L W ■! 4 1 iOO ISO 100 SO Fig. 1. Trend of general commodity prices for past 100 years, showing ele- vation during Civil War compared with recent war. (Furnished by New York Federal Reserve Bank.) Chart No. 8, are, despite their recent heights, now near their 1914 level and some of them are lower. Here, too, the signs all point downward with every in- dication that prices have still further to go. The position of real estate is we see that at the beginning of the Civil War commodity prices soared, un- til at the peak they reached about the same point through which we have just passed. At the culmination of the war prices started downward and continued to decline for 31 years until 1807. This marked the end of the post-war depres- sion and the beginning of the accumu- lation of new wealth. We have now passed the peak of commodity prices following the recent war and find that the curve reached nearly the same height as in the Civil War. Sufficient time has now elapsed to show that the decline is at the same rate. We have just reached the first break in the down- ward trend, with every indication that we are about to repeat the experience of the past. The following basic com- Fig. 8. Composite chart showing prices of rubber, copper, iron and leath- er to have reached above 1914 level. / 1 1 1 ^ ^ — ^ ^ 1 1 [ \ Fig. 2. Curve represents average real estate prices over past 25 years, showing peak of prices during war. modities: Petroleum, wheat, corn, cot- ton, coffee, wool, hogs, steel billets, cop- per, leather, and rubber, the last four of which are illustrated on composite shown in Chart No. 2 and the downward indications may be noted. On Chart No. 4 the dotted line represents commodity prices and shows how they are making for 1914 levels. The dark black line rep- resents construction costs. In 1920 they were 160 per cent and are now 100 per cent above the 1914 level. Here again the trend is downward. The lower thin line represents house rents, slow to rise, but with falling construction costs and commodity prices, certain to come down. If rents are lowered the value of real estate will be correspondingly low- ered, since income is the basis of val- uation. There seems to be every indi- cation that real estate will reach its 1914 level and if the past is a guide to the future, that it will break through this level and continue its downward trend for possibly twenty-five years. If the physician is partial to his old type of investment and continues to purchase real estate he will be unsuc- cessful. The rising tide on which he then floated has reached its full, turned, and is now falling. Real estate bought in the future will become worth less each year until the war debts of the world have been paid, the enormous wealth destroyed shall have been re- placed, and new wealth shall begin to accumulate. This required 84 years for the Civil War, and how long it will re- quire for this war is beyond conjecture, SOUTHERN MEDICINE AND SURGERY January, 1922. but SO far we are proceeding to deflate at exactly the same rate. ""^ 1 — 1 p . r\i i -L / 1 " • ■ ' /■., \ 1 ' ■ 1 ■ 1 '• ■ / ; ■ '■■■' / '■" 1 / ; 'i / ^ .. ' / .A •^ ' '" / J jJl 1 ' "' .■■ .JO ./^ 1x ... ""■•>' '■ ' ■V y'' ! '"■ .•■■■, y ^-^ 1 k 4- fo 5 -jrrr irnr ^?r^- ... !■>."> L_ L- u _^ _ Ll....iH nearly doubled in value. Here the trend is upward and each purchase may be made with the prospect that it will be worth more each year for many years to come. In this way one may again float on a rising tide instead of trying to buck the downward trend. Another advantage in the bond investment is that they do not have to be repaired or insured. There is no loss from being vacant or commissions for the collection of rent. Used as collateral they are more acceptable to banks than real es- tate. Fig. 4. Dotted line represents com- modity prices. Light line house rents. Dark line construction costs, showing comparative changes of same from 1914 to 1921. (Monthly Market Letter, Good- body & Co.) The requirements for a comfortable dotage are still the same. To live on less than you make and invest "the dif- ference," but a new medium of invest- ment must be found. It seems to us that the greatest profits will be reaped by those who invest "the difference" in the bonds of our railroads, industries, and public utilities. In 1914 forty representative bonds sold at an average of 89. These same bonds may now be bought at an average of 71, as indicated in Chart No. 5, or lower than they have sold for the past twenty-five years. The equities behind these bonds are no less and in some in- stances war profits have made them more secure. Before the war such bonds could be sold to return 4 per cent on the dollar. With the destruction of wealth, the demand for money on which to maintain operations and to secure na- tional existence, led borrowers in their urgency and competition to force the price of the dollar up to about 8 per cent. New securities were issued on this ba- sis and old ones decreased in value, un- til their yields were brought into proper alignment. Peace, industry, and econ- omy will lead to the creation and accum- ulation of new capital. Borrowers not spurred on by war profits or pushed by national necessity will offer less for money, until the lack of demand and a bountiful supply will find the dollar again where it rents for 4 per cent. At suqh a time bonds bought now will have lU 1 ' ■ „ ~ ~ ~ - ~ -TV ■ 1 — l\ » / \ \ \ \ li /\/\/ ^ 1 1 ilu -t\ A A / \/ \ \ A ^ V 1 / <.> N / 4 •- ^ T 1 f \l _ _ _ . _ _ _ IVi iVS ffU ^ IVf !VJ 11^0 / ti. Fig. 5. Average price of 40 bonds during past six years. (From Magazine of Wall Street.) There are bond houses, the reliability of which is beyond question. They will gladly submit you lists suited to your needs. Your banker will furnish you with their names. A good representa- tive bond list is to be found in the daily papers. Bonds may be bought on the installment plan with payments extend- ing over a year, or they may be bought on open account, providing one-tenth their value is paid down. Simple in- quiry will bring you a wealth of detailed information as to how such transac- tions are conducted. In conclusion it seems that if he would temper the pangs of old age with the comforts of wealth, that the doctor must live on less than he makes and invest "the difference," that real estate, the old favorite, has reached the peak of its m.ovement and will decline for years, that bonds have struck bottom and will move upward for a long time, that doctors who invested in real estate should now change to bonds in order that they may take advantage of the change in the trend of the times. January, 1922. ORIGINAL COMMUNICATIONS 13 from 15,000 to 30,000 as a rule. Cys- THE DIAGNOSIS AND THE TREAT- toscopic examination of such a case should readily clarify the diagnosis by MENT OF DISEASES OF THE KID- bringing down some pus in the urine of NEY PELVIS AND URETER. the affected side. We make it a rule to take the patient to the X-ray room By Byrd Charles Willis, M.D., F.A.C.S. and have film made before and after Rocky Mount, N. C. filling of the pelvis and ureter with 25 ^, , r ^ ■ ir xu 1 • 1 per cent sodium bromide. By this The prevalence of lesions of the kid- j^gthod, in one examination, a stone, ney pelvis and ureter in this section of stricture, hydronephrosis or dilatation the state IS my reason for bringing this ^^ ^^^^^^ ^^ discovered. Should subject to the attention of the society. ^^.^^^^ ^^ ^^^^^ j^^j^^^ ^^ present, and In the past year we have admitted to ^^^^ ^ considerable amount of pus be Park View Hospital 1,101 patients of -^^^^^ -^ ureteral catheter specimen, a whom 88 had some lesion of the pelvis diagnosis of uncomplicated pyelitis is or ureter requiring investigation and justified. The mere cystoscopic exam- treatment. During the year 303 cysto- -^^^-^^ ^^ bladder, while of value in scoDic examinations and treatments showing cvstitis, ulcers, stones, diverti- T?nTn^'^; J^ !\ \"^^r^^.^'"^ ^°v,"? culum pouting and oedema of ureteral that 950 of the total admissions had a ^ j^gs is inconclusive unless supple- trace of albumin to a marked albumi- ^^^^^^ ^^, ^^^ ^^ove. nuria. This is certainly a very high j^^ ^jj j^^^^ ^^ suspected appendicitis percentage and if the experience of ^^ ^^^ ^.^^.^ ^^j.^^^,, -^ q^,^ history to other hospitals in this section is the ^^^^-^ ^^^ ^^^^^^ location of beginning same an inve.stigation should be made as ^^ ^^-^ whether it began over the belly to Its probable cause. ^^ -^^ ^^^ ^i^^ ^^^ extended to the belly, A^odern urology with its armamenta- jf the latter and an associated temper- rium of cystoscupe. bismuth catheters, ature of 102 degrees or above we are waxtipped catheters, non-toxic shadow very stronglv suspicious of pyelitis, casting medium, and X-ray has rendered especially if there is any bladder dis- the diagnosis of diseases of the kidney turbances. There will be no history of pelvis and ureters one of the most ex- radiating pain to the symphysis unless act in modern medicine. As an adjunct there is some blocking of ureter due to to surgery it is indispensable, for lesions passage of clots, stone or swelling shut of the kidney pelvis and ureter so close- of ureter lumen. ly simulate acute surgical conditions of This classical symptom of pain ra- the abdomen that it is impossible to diating to the symphysis and testes is differentiate without its aid. not infallible, for we had a male patient What are the common conditions who complained of pain in his right found? Pyelitis and ureteritis due to testes, and had blood and a few pus some infection, hydronephrosis, stric- cells in urine, and after several days' ture of the ureter with or without dila- delay operation revealed a ruptured ap- tation, and blocking of ureter by a stone pendix at juncture of bladder near in- or intra-abdominal tumor. The symp- ternal ring. toms of acute pyelitis are chills, fever, I would like especially to call your nausea, possibly vomiting, pain and attention to the tenderness experienced tenderness on the affected side and by the patient on palpating the course along the course of ureter, and rigidity of the ureter and if on the right side of the muscles of the flank shading over can easily be mistaken for sub-acute ap- on the abdomen. Without an examina- pendicitis. The differentiating points tion of the urine one can very readily are, point of tenderness is not under make a diagnosis of acute appendicitis McBurney's point but half way between if the attacks should be on the right it and the umbilicus, and along the side. However, the urine may be en- whole course of ureter with slight ten- tirely negative for if the patient should derness of the kidney; vaginal exami- have a stone blocking the ureter the nation may show tenderness and thick- urine would necessarily be negative as ening of the lower end of ureter, in one of our recent cases. The white Simple hydronephrosis due to stric- blood cell count rarely goes to 15,000, ture at uretero-pelvic juncture or kink- whereas in appendicitis the count ranges ing by anomalous vessel presents few 14 SOUTHERN MEDICINE AND SURGERY January, 1922. symptoms of diagnostic significance ex- culture is made of ureteral specimen of cept tumor and aching at crest of ilium urine there will usually be found a cr flank, which may be intermittent due growth as a low grade infection is often to change of position allowing the kid- associated with the disease, ney pelvis to empty. When a ureteral Stone in ureter usually gives very catheter is introduced into the pelvis of characteristic symptoms and attacks of such a kidney there is a steady flow of intense pain starting in the kidney re- urine due to escape of retained urine, gion radiating to the symphysis or There is no peristaltic spurt of urine as more rarely to pit of stomach, if in the seen in normal or other pathological male to cord or head of penis. Urinary conditions of the pelvis and ureter. We examination is of great value as blood have siphoned off as much as 24 ounces and pus in varying quantities may be from one sac — any amount above 20 c.c. found, but not always for the stone may may be considered abnormal. be blocking ureter causing retention of Stricture of the ureter is either con- pus and blood in the affected side. Cys- genital or acquired. The acquired type toscopic examination of bladder may be follows ulceration of the ureter, passage negative unless stone is hung in mouth of stone and thickening due to infec- of ureter and visible. Passage of ure- tion. The symptoms of this disease are teral catheter, wax tip, may reveal ob- very obscure and often misleading, in struction or difficult passage, and on the female, patient is often told that she withdrawal show scratch on wax char- has ovarian disease. Back and hip ache acteristic of some rough object. X-ray with the greatest point of intensity at will usually show stone but we must re- the crest of ilium, radiating to lower member that 10 to 15 per cent of stones belly is very suggestive of stricture, are not shown by the best roentgeno- The urinary findings as a rule are prac- legists, and further the X-ray may be tically negative two to five pus cells to misleading in that shadows of phebo- the low power field and occasional blood liths must be differentiated by the use cells. Some slight tenderness may be of bismuth catheters and shadow cast- elicited along course of ureter, more ing media injected into kidney pelvis marked above the symphysis. Up to and ureter. Tuberculosis of the kidney this point the diagnosis is made by ex- pelvis and ureter are not taken up in elusion of other diseases. Cystoscopic this paper because we believe it is never examination reveals a normal bladder primary but secondary to tuberculosis but small rounded ureteral openings sit- of the kidney itself, uated on apex or side of mound, if the The treatment of the above condi- stricture is at ureter outlet. Further tions is medical, surgical and combined, observation of the opening will show Medical treatment from the standpoint rythmic pouting followed by prolonged of a general practitioner is effective and spurting of urine. It will be difficult curative in simple uncomplicated cases to pass a No. 5 ureteral catheter owing of pyelitis and ureteritis, and palliative to inability to fix ureteral opening on in the others with the possible exception wabbly mound and the minuteness of of small ureteral calculi. In the latter opening. The diagnosis is clinched by large quantities of water and morphine passage of catheter and injection of pel- for relief of pain and as an aid in re- vis to kidney to point of distension and laxation of ureter walls will often ma- patient complaining of similarity of terially aid in mechanically pushing pain to that they suffer, and further down a stone but this method should confirmation made by X-ray picture not be tried too long because it has showing slight dilatation of pelvis and been shown experimentally that by ty- ureter. The X-ray may be of no value ing off the ureter for 48 hours the kid- except for exclusion of stone in ureter ney will permanently cease to function- and other diseases. If the stricture is ate, and who is able to tell without the higher up the passage of a bulb or wax aid of the cystoscope that the stone is tip catheter will reveal an obstruction not completely blocking the ureter, by inability to pass all the way to the In simple pyelitis we believe in a pre- kidney or it will hang and finally pass liminary cleansing of the intestinal with a hanging sensation, and disten- tract with broken doses of calomel fol- sion with fluid will bring out similarity lowed by some brisk saline purge, and of pain, and X-ray reveal moderate dila- give a glass of water every hour, and a tation of ureter and kidney pelvis. If dram of bicarbonate of soda every four January, 1922. ORIGINAL COMMUNICATIONS 15 hours for five or six days, together with damage is done to the kidney, rectal tap of continuous soda solution, Hydronephrosis is a surgical condi- and put patient on light diet with no tion as soon as the diagnosis is estab- dark meats If they have a high temper- lished because as yet we have no other a^ure we put them on liquid diet. We means of relief, and the retention of then switch to acid sodium phosphate such a condition injures the good kid- (frrains thirty) in sufficient doses to ney, and there is further danger of a sFrongly acidify the urine, and give for- pyo-hydronephrosis developing at any min (urotropin hexamethylenamin) time, which is a much more serious con- grains ten every four hours because dition and more difficult to deal with formin is onlv effective in an acid urine, surgically. Large stones incapable of If this is not effectual in another week passage down the ureter without se- we discontinue the acid and formin rious damage to the kidney should be treatment and alkalinize the urine and dealt with surgically. Moderate size use cystoscopic treatment dilating the stones in the kidney pelvis complicated ureter with a large ureteral catheter to by an infection should receive surgical aid drainaf^e and irrigate the kidney attention because any blocking of the pelvis with ascending strengths of sil- ureter brings on a pyo-hydronephrosis ver nitrate beginning with a half and with serious damage to the kidney. ending with three per cent. These cys- toscopic treatments are given from three to five days apart usually, though TiiRFRriTT ^^T^ IN INFANCY the interval of treatment is dependent TUBERCULOSIS UN UM-AJNt^Y upon the ability of patient to take the Hy Dr. H. H. Harrison. Asheville, N. C. treatments because in some there is considerable reaction marked by chill I realize the commonplaceness of my and rise of temperature. This we des- subject, and do not claim to offer any- ignate as combined treatment. thing new or original, or to cover it. Medical treatment of stricture is in- But, having run into several cases late- effectual iust as it is in stricture of the ly, the importance of bearing it con- urethra with retention unless the stric- stantly in mind as a possibility m many tnre is dilated, and as the general prac- conditions of infancy has been impress- titiorer has no method of dilating the ed on me. , . . ureter at home nor the time to spare. To begin at the beginning, we know the case properlv belongs to a specialist that it is almost never congenital, but in urologv or one who is equipped to that every infant has a very high grade handle the case. Strictures of the ure- susceptibility. The probabilities are ter are dilated bv the passage of large that no considerable immunity is con- ureteral catheters with or without bulb ferred on the child either through the tins allowing them to remain twelve to placenta or through the breast milk, twenty hours at a sitting. Of course, though on this last I have been able to the cystoscope is removed, and patient find no authoritative statement. On the returned to bed. Stricture at the mouth contrary if the mother has open i B. of ureter mav be cut with special scis- the infant is almost sure to die with it, sors or a catheter mav be passed into unless isolated from her immediately ureter and cystoscope shoved downward after birth. The statement has been and stricture torn open. . made by Dr. Dunn, of Boston, that m Small stones in the ureter may be re- infancy it is as infectious as scarlet te- moved by passing several catheters into ver. It seems to me that it might easily ureter bevond the stone and allowing be more so, for the infant is cornpara- them to remain twentv-four hours. As tively immune to scarlet fever. .At any an aid sterile oil mav be injected into rate it is a wise and sate conclusion that ureter just before removal of catheters the infant who is exposed tor any and large quantities of water given to length of time to an open case acquires aid mechanically in pushing down stone, the disease. Ninety per cent of these The injection into ureter of weak solu- under one year will show symptoms ot tions of cocaine to relieve pain and re- activity within a period of months in lax the muscular walls of ureter will the second year they are slightly less often aid in the passage of the stone. .., xt ^ A,r ^ i f „ of If this method fails surgery should *Read before the N ^ Med.cal meeting at be resorted to for relief before too much Pinehurst, N. c, Apni, I92i. 16 SOUTHERN MEDICINE AND SURGERY January, 1922. susceptible, but if we consider all these as being active we will be right in the large majority of instances. We learn from some of the large clin- ics that its rank as a cause of death is high, the alimentary diseases and acute infections alone standing ahead of it in infancy after the first month. This fact comes not from the ward but from the autopsy room, where even with the elect diagnosis has to be changed once in a while, and in something like 30 per cent it is present when death is due primari- ly to another cause. In a large series of necropsies in infancy 23 per cent un- der one year were positive for T. B., all under two years 40 per cent were posi- tive. These figures are from Bamber- ger, of Leipsig. Dr. Dunn, of Boston, gives 20 per cent of 128 necropsies un- der two years as positive. These are all from a large city population and may be slightly higher than the general average. There is certainly a greater incidence in Europe than in America, and of course it varies a good deal with different localities. I do not think much T. B. is contract- ed except by actual contact with active cases, and I am one that believes that in the great majority of cases it is im- planted in childhood, and if we bear in mind the old established fact that every infant is highly susceptible, we may contribute a great deal to lowering the death rate. At the same time I believe that the child, not the infant, who gets it but who does not get much activity, and this I believe is a question of dos- age rather than of resistance, is a much more fortunate child than one who does not get it until later on in life. For I think the slowly diminishing death rate of T. B. is due to an increasing preva- lence of it and the consequent immunity more than to preventive measures or better methods of treatment, though I would not in the least depreciate the value of these. How better can we ex- plain it when we remember the fact that the incidence of tuberculosis is on the increase. During infancy all tuberculosis is ac- tive, for as we have seen there seems to be little protection from the mother and no active immunity is present to help fight off the invasion. As to pathogenesis: Opie states very confidently, "We have reached a satis- factory understanding of these mat- ters." It has been amply demonstrated that at least in this country the infant in the great majority of cases gets T. B. just as the adult does, from associa- tion with active cases and through the respiratory tract. Opie and Dunn of this country, Bamberger and Ghon of Europe, among others, have made rath- er exhaustive studies of this and all agree, finding the lungs and bronchial glands far more often infected than any other part, and in the large major- ity of cases they give evidence of being the oldest lesions. Ghon studied more closely the lungs, making thin sections of the entire substance and going over these with bare fingers he was able to find the locus of first implantation in practically every case. One of our own investigators finds that by a radiograph of the lungs after being removed from the body gives the same results — and in every case when the bronchial glands are affected the lungs show more or less evidence of trouble. In 184 autopsies by Wollstein and Spence on tuberculous children, five only showed lungs not in- volved, and seven only showed bronchial not glands involved, hence, I think we can conclude that this is the route by which the infant becomes infected in something like 95 per cent. Bovine type is rare in America and is most commonly found in the cervical nodes or abdomen. Nine out of 362 autopsies on the infants. Lymphatic tissue is by far the most vulnerable part of the infant, next the serous surfaces (which, I believe, pa- thologists say are really lymph spaces) and next the lungs. Most writers speak of the infected lymph nodes draining from the primary implantation as a part of the initial lesion. The spot of the lung more often becomes quiescent, while in the lymph gland it smoulders, terminating in resolution, caseation, fibrosis or abscess, just as we have ob- served the cervical glands to do except in the infant progress is much faster, glands breaking down in weeks rather than months. The secondary lesions depend on whether the infection dissim- inates by the lymphatics, the blood stream, by bronchus or by contiguity. If by the blood stream we have a gen- eral milliary, and the predominating picture in this case is usually tubercu- lous meningitis, or if into a pulmonary artery we have milliary of the lungs. If by a bronchus a tuberculous bron- chial pneumonia, or it may spread by January, 1922. ORIGINAL COMMUNICATIONS contiguity often along an interlobular fissure, or the spot of primary implan- tp.'ion may develop and give the appear- ance of lobular pneumonia or may case- ate and form a cavity. When the initial lesion is in the gut and messenteric gland we may also get dissemination by blood, lymphatics or contiguity. Prognosis is absolutely hopeless only in m.eningitis and in general Milliary But even in the primary stage is not good, but grows better constantly with time. As to diagnosis: To go into that of all the possible secondary lesions would make the paper entirely too tiresome. The modest of onset in all tuberculous lesions is usually worth a great deal. Meningitis and bronchial pneumonia are by far the most common in infancy, and if we but bear tuberculosis in mind, proof for or against it may usually be had. In meningitis the different forms, namely, spastic and flaccid, are to be remembered, for they are very definite. Apathy, loss of weight, vomiting, con- stipation, stupor, convulsions, rigid neck, stabismus, p.iralysis and the lum- bar puncture findings usually make a diagnosis, although syphilis, secondary or polioencephalitis, should not be lost sight of. In infancy secondary lesions of the chest are next in frequency, it being usually a broncho-pneumonia, and I dare say there are few diseases that are more often misdiagnosticated. It is true that the mistake is not such a grave one, for treatment does not promise a great deal. When an insidious bronchitis hangs on, say, two weeks, that is progressive, get busy and prove that it is not T. B. His- tory of exposure, D'Espino, von Pirquet, X-ray of chest, quickened pulse, fine constant rales around the nipple or an- terior axillary fold, and repeated sput- um examinations will usually be suffi- cient. But so-called peanut bronchitis, pulmonary abscess, low grade broncho- pneumonia, delayed resolution, empye- ma with adhesions and a condition fol- lowing influenza are to be thought of. An interesting point on this subject to me is the large prevalence of cases showing secondary symptoms in the late winter or early spring in the two or three years just following infancy, showing that at this period the child might get by all right if it can be shielded from certain conditions that obtain at this time, which probably are: the deprivation of fresh air through the winter, the over-heated house, a greatly reduced vitramin content in the winter foods, and probably the most important — the respiratory infections of winter. But to get back to the infant: How are we to make a diagnosis during the primary stage, that is, before it spreads from the place of implantation or adja- cent lymph nodes at a time when we can probably, almost surely, do some good? It is up to us to do it if we are to advance our science. We must bear these incurable conditions constantly in mind, and when there is a possibility of their presence, "Seek diligently." We can usually get pretty definite informa- tion if we will but take the trouble. The von Pirquet test, if positive, is ab- solute evidence except just following measles. If negative, it should be re- peated, and if the child is very atrophic or anemic it may continue to be nega- tive until the general condition is im- proved. It has been found in most cases in which we are not sure of the reading that in reality it should be read positive. IVEspino and spinal dulness has been found to be positive in over half the cases that come to autopsy. This sign must be elicited at or below the thii:d dorsal vertebra to be of value. Some of the acute respiratory infections may give enlargement of the bronchial glands and this should be borne in mind in making examination. It is rare that they are large enough or numerous enough to cause a positive D'Espino. They do not persist like tuberculous glands, and can in most cases be dif- ferentiated by X-ray, which is the mos'; dependable diagnostic test after von Pirquet. By a trained roentgenologist, that is, one who has had much experi- ence in just this sort of work, positive evidence can be gotten in something like 75 per cent of tuberculous infants in this country and 20 per cent of the remaining 25 will show suspicious mark- ings according to Dunn if taken not too soon after infection, for it must be re- membered that a dense fibrosis of a gland, caseation or calcification is nec- essary to cast a shadow, so a negative plate does not always exclude T. B. There may also be at this time anemia, failure to gain, difficult feeding, slight elevation of temperature, and some of these cases merge gradually into maras- 18 SOUTHERN MEDICINE AND SURGEUY January, 1022. mus without ever having fever or getting a small number of tubercle ba- cough. cilli in our system is to be regarded as In some few cases pressure symptoms a "friendly act," but how many, when, of the enlarged glands may be the first or how often is it good to have them— I indications. It is to be recalled that the trust some day we will know. structures that may be encroached on and thus cause symptoms are the pneu- mogastric, recurrent laryngeal nerves, THE USE OF BONE AND FASCIA superior vena cava, trachia or bronchi, GRAFTS IN THE RECONSTRUC- and the symptoms that would_ follow TION OF BONES AND JOINTS. may be easilv figured out. This form „ . ,,. ^ „ . ,t t^ ^i. i ^.i. t.t /-. of trouble is commonest after the period ^^ -^^^''-" ^- ^^ ^' ^^•^•' ^^^^•^°"^' ^- ^- of infancy. Bone and fascia, and fascia, covered As to treatment: In the secondary with fat, are excellent grafting mate- stage there is little that promises much, rials for the reason that they heal with- but to make the patient as comfortable out reaction and easily become incor- as possible for the proper time for treat- porated with the tissue into which they ment is past. In the primary stage we are ingrafted. Bone must be ingrafted can be much more optimistic. The first or contacted to bone, whereas fascia thing to do is to get the co-operation of may embrace or be embraced by any the parents, explain to them the situa- tissue whatever and grow, tion and the mother will more than as- A graft of bone, cut from the same sist you. These children should be kept individual to be grafted, as one would in the very best physical condition. Cor- cut a slice from a mellon, including skin, rect feeding takes on a tripled import- rine and meat, that is periosteum, cor- arce. with fats, protein and vitamins to tex and marrow, requires, in addition the limit of absolute safety. The child for its life and growth, only a healthy should be kept in fresh air always and bed, the attainment of asepsis and the out of doors all the time except in win- maintenance of immobilization, ter months, should be shielded absolute- It has been many times proven that ly from any possible exposure to infec- bone so grafted and contacted at its tions, especially those of the respira- ends with the recipient bone, even at a tory tract, and lastly I believe in tuber- distance of six or more inches, has culm we have a remedy, not a specific, grown, has become fractured and has that should always be given at this repaired its own fracture, stage of the disease providing the child It is just as certain, on the other IS m a fair condition of nutrition, but hand, that the bone graft does act as a given with the greatest care. It is not stimulus to osteogenesis to the bone a cure, but simply a stimulant to the into which it is ingrafted, curative eff'ort of the body. When given While the structural conditions of the properly I think it capable of doing skull for the reception, for the support much good, but weight curve, temper- in a fixed position and for the blood ature, pulse and the sight of injection cascular supply, are all good and favor- should be closely watched. The unpop- able to the life of the grafted bone, ularity in the use of tuberculin is prob- osteogenesis, on the part of the skull ably due to the difficulty in determin- bone, is ordinarily very weak. Defects ing the appropriate dose which always in the skull show little spontaneous requires time and the utmost pains, tendency to become filled with bone, dif- There seems no way to arrive at the fering especially from long bones, which therapeutic dose from the clinical find- fill very rapidly, ings, but only by closely watching the Three head cases to be cited directly patient while cautiously increasing the were of one, six and fifteen years dura- amount, tion ; they all showed but little growth I believe the time is not far distant of new bone around the edges of the when we shall understand how to im- opening and that irregular. The same munize or vaccinate infants and chil- cases showed an even covering, at the dren against T. B. just as we do diph- location where the bone transplant was thena and typhoid. It is an established taken from the tibia. fact that the wave of tubercular mor- In the case of the skull we have a tality is on the down curve, while the beautiful demonstration of the fact that incidence is increasing, this means that bone takw from elsewhere in the body January, 1922 ORIGINAL COMMUNICATIONS 19 and placed where functional demands Marshall adds : "Where great f unc- are made upon it, it will grow, and will tional demands are made upon the fas- grow in a location where spontaneous cia, as when it is used to repair tendons, regeneration of bone on the part of the it gradually takes on the structure of skull is very weak. In the case of the the tendon, so that after three months tibia, where the graft was taken, we it can not be distinguished from it. have a demonstration of the phenome- When it is used to repair defects in the non that bone will regenerate to the abdominal wall, the same process takes point demanded by the functional forces place, but more slowly, the transplanted acting upon it and no further. These fascia finally assuming the structure of facts are amply illustrated in the case the surrounding tissue. In the thoracic reports to follow. wall where there is less tension and I have referred above always to the where tension is more uniform, the fas- autogenous graft. Where it is to be cia retains its original structure, even expected that a graft of any tissue it- after a year when all progressive proc- self grow, it must be autogenous or esses have stopped. The elastic fibers possibly taken from an individual of of the fascia are not only preserved, the same blood group. Usually homo- but they increase and penetrate the sur- genous grafts as well as heterogenous rounding cicatricial tissue, changing grafts become absorbed, but they may the character of the scar so that it ba- be used as splints and supports in the comes more elastic." body for a time. In bone they have the Fascia has been used in the body, in advantage over metal, in that metal man, in a great variety of situations and actually inhibits bone formation, pro- for numerous purposes: for bridging duces bone absorption and favors in- defects in muscles, tendons or liga- fection. Living and boiled bone splints ments, for spanning openings in the from other individuals and even boiled walls of body cavities, in hernias and bone from animals does not retard bone weakened abdominal and thoracic walls, growth and likely stimulates new bone for fastening parenchymatous organs formation in the surrounding bone in place, in correcting rectal and vaginal where grafted. prolap.^e. to suspend the kidney, to oc- The credit for the establishment of elude hollow organs, to strengthen su- free transplantation of fascia as a ture lines in such organs, for covering method in plastic surgery belongs to amputation stumps, for mobilization of Kirschner, who was the first to write resected ends of joints, for filling in an extensive paper on the subject and bone cavities, for filling in defects of to show by experimental work its va- soft parts in plastic surgery, for cover- rious possibilities. Quoting Kirschner: ing tendons as sheaths, for covering "One of the chief reasons why fascia nerve sutures, to replace the dura in is such an excellent material for trans- brain operations, etc. plantation is that it heals without re- Recently I have used a strip of fas- action ; both in cases where it is at rest cia, from the fascia lata, to relieve ten- and where rather severe functional de- sion on the suture line and support the mands are made upon it, autoplastic flaps in the operation for cleft palate, fascia shows a marked tendency to be- with the most satisfactory results. come incorporated with the neighbor- Whenever possible, as with bone, au- ing connective tissue. This often oc- tcgenous transplants or homogenous curs even when asepsis has not been transplants of fascia from an individ- perfect. Some surprising results have ual of the same blood group should be been obtained in covering over infected used. organs. The transplanted fascia may Binnie, in speaking of "Some Uses of undergo changes, such as swelling and Fat in Surgery," says: vascularization and may be transform- "In spite of its reputation as a tissue ed into connective tissue and fat, but in of poor resisting power, fat is well suit- many cases it remains intact in its orig- ed for transplantation. In many in- inal form. Fascia has the advantage stances it is undoubtedly the connective over other tissues in that it is easier to tissue basis of the fat which is of value obtain and in large amounts. There are in the transplant, but in other instances no serious results which have followed other varieties of connective tissue the removal of even large areas of fas- would be valueless compared to that cia lata." which is infiltrated with oil." 20 SOUTHERN MEDICINE AND SURGEUY January, 1922. My case report and illustrations will filled in and the patient improved after srive the reader a fair idea of some of four years. the uses of bone, fascia and fat in the Case 3. A young man twenty-four reconstruction of bones and joints and years old, wounded the day of the sign- of the technical points in making the ing of the armistice, gun shot wound transplants : of the skull in the occipital region with Case 1 : A man thirty-five years old, comminuted fracture, primary debried- whose head was severely crushed in a ment, wound four months in healing, railway accident six years previously, during following eight months back of At this time his head was trephined head became markedly bulged and the and some bone sDlinters removed, overlying scalp thinned out. On No- Shortlv after this he developed "spells" vember 9, 1919, there was a marked when he would lose consciousness and bulging over the occipital region and a "spasms," mostly on the opposite side, defect in the skull 6 cm. by 8 cm. There Speech slew, apperception dull. There were no focal symptoms. Fig, 5 is a was a large depression over the left side back view. Fig. 6 is a profile view of of the skull, the soft parts drawn down the patient four months after the oper- tight and the bone deficient over an ation. Fig. 7 is the skull filled in by the area about 4 cm. by 6 cm. The soft graft and Fig. 8 is the left tibia, from parts were loosened ud, the scar tissue which the bone shells were taken, removed, the callus around the edges Case 4. A young woman with mark- cut away and the edges beveled at the ed scoliosis and kyphosis. Fig. 9 is the expense of the outer table. Into this case before operation ; Fig. 10 is the defect was grafted a rectangular bone approximate condition of the spine be- shell taken from the tibia, cut and bev- fore operation; Fig. 11 is the same case elled to fit. A few stitches were placed after operation; Fig. 12 is the bone to unite the periosteum of the graft transplant embedded and growing in with the nericranium, and the wound the split spinous processes, redressing closed. The graft was covered with the spine ; Fig. 13 is the site on the left periosteum and was cut just to the mar- tibia where the graft was taken, row cavity. Fig. 1 shows a picture of Case 5. Fig. 14 an X-ray of the spine the man six weeks after the operation in this case shows the tuberculous le- and the site of the old skull defect filled sion of the seventh and eighth thoracic by the bone transplant. Fig. 2, the site vertebrae, with marked kyphosis and where the graft was taken from the slight scoliosis : Fig. 15 is a picture of left tibia ; the origin of the graft is well the patient after the operation ; Fig. 16 filled in and smooth even after six shows the amount of flexion of the spine weeks. The case was operated on about possible in this case after operation, six a ye^r prior to November, 1916, and the months later. last I heard from the man was that his Case 6. Fig. 17 is the X-ray of the i5ead was well closed and that he had spine, showing scoliosis and some ky- not had a spell in a number of months, phosis; Fig. 18 is the girl after opera- Case 2. A man twenty-two years old, tion eight weeks later ; Fig. 19 shows kicked in the head by a mule fifteen the amount of flexion possible at this years previously. Some bone was re- time; Fig. 20 is the case seven months rnoved, some came out from time to later and Fig. 21 shows the added time, leaving his head sunken in. He amount of flexion at this time, formerly dragged the leg on the oppo- Case 7. Figs. 22 and 23 are anterior- site side and dropped words. Had great posterior and lateral views of a tuber- deal of headache and pain over the de- culosis of the third lumbar vertebra; pression. Head was trephined a year Fig. 24 shows the woman five months ago. symptoms were better for a while, after the operation and Fig. 25 the again worse. Depression and opening amount of flexion at that time. in the skull about 3 cm. by 5 cm., the Case 8. A young man fourteen years soft parts were drawn and attached, old with tuberculous spine in lower Fig. 3 is a picture of the patient two lumbar region, with marked kyphosis v-eeks after the operation and of the and pressure on spinal nerves. The pa- site of the skull defect filled in by the tient was bed-ridden. Fig. 26 shows grrft, and Fig. 4, the location on the the boy three years later. Fig. 27 the surface of the left tibia where the graft amount of flexion at this time ; Fig. 28 was taken. The skull remains evenly the graft at this time, showing marked January, 1922 ORIGINAL COMMUNICATIONS 21 increase in size. The patient has been Case 14. Figs. 45 and 46. This case working on the farm and ploughing for of tuberculosis of the hip joint was the last two years. Fig. 29 is the tibia fixed and ankylosed in flexion and at this time, well filled in and shows no marked internal rotation. The head of sign of the removal of the graft except the femur was resected, the acetabulum the thickening of the cortex. reamed out and fascia with fat inter- Case 9. Fig. 30 shows the setting in r)osed. The illustrations show the thigh plaster of a compound fracture of both in extension and flexion and the amount bones of the forearm. Fig. 31 is the of motion possible. The patient walks same arm rebroken while still in the well and has done hard labor for the plaster. This happened while the pa- last five years. tient wa^ riding a mule along the side Case 15. Fig. 47. Another case of a of a hill and the mule fell and rolled resection of an ankylosed tuberculous over on his arm. One callus held, the hip joint, with interposition of fascia other broke and one of the bones was and fat. Amount of flexion shown. The fracture:! m still a third place. Fig. 32 young girl has been walking for four shows a sliding graft in the radius, four years. Scars of two previous opera- weeks after the grafting. Fig. 33 shows tions may be seen the same graft after ten weeks. The ^^^^ jg pj ^g ^ So-called arm is qui e strong and a remarkable j^^.^j^^,^ ^he plates are from two dif- shaping and straighenmg of both bones ^.^^^^^^^ ^^^^^ ^^ ^^U^^^ ^.^j is to be observed. Ihe man has a before the operation and the two feet of the other after the operation. The metatarso-phalangeil joints of the straight and perfectly functionating arm. Case 10. Case of fracture of the neck . . resected and nedicled of the femur, occurring in March 1919. ^^^f/alflaprTnternt^ed across [he'lt The patient, at first, walked on the leg ,^^^^^ ends-Mavos operation. The until walking became impossibe early ^^ ^^ ^^ j. • ^ ^ . . ^ in the Summer and the leg rolled out .^.^ ^^.^. ^^ ^^^^ing and total func- and became shorter In September the ^j^^ ^^^ exJellent. fracture still showed no union and little or no callus, as seen in Fig. 34. Fig. References 35 shows the fracture after redress- Albee, Fed. H.: The inlay Bene Graft Ver- ment and a bone graft, pegging the sus Lane Plates in the Treatment. Fractures, neck of the femur, ten weeks later. Fig. Am. Jr. of Surg., March, 1915. 36 is the case six months after the Brenizer, A. G.: Bone Grafts Into Skull operation, with the leg in extension ; Defects. Annals of Sura:., Nov., 1916. Fig. 37 is the case, showing the amount Brenizer. A. G.: The Use of Intra-medul- of flexion. lary and Extra-cortical Beef Bone Splints in Case 11. Another case very similar the Repair of Lona: Bones. Surg. Gyn. and to Case 10. Fig. 38 shows the case a Obstet., Feb., 1920. year after the operation, with leg ex- Blnnie, J. F.: Some Uses of Fat in Sur- tended ; Fig. 39, with leg in light flex- sery. Surg. Gyn. and Ob.-.tet., March, 1914, ion ; Fig. 40, with leg in forced flexion, v. 18, p. 3:i6. Case 12. Paralytic club foot. Fig. Binnie, J. F.: Manual of Operative, Surg., 41 is picture of foot corrected by length- p. ifi; 612. Phil. p. Blakiston's Son & Co., ening tendo achilles and spreading 1916. scaphoid by cutting out a wedge of bone Funks: Centralbl. f. Chirurg, 1915, VIII. and using it to hold the scaphoid open. p. 257. After four to six weeks in plaster, the Hirshberg, L. K.: Surgical Transplanta- shoe is raised on the outside and the tion, Med. Council, Dec, 1915, v. 20, p. 30. simple splint, seen in Fig. 42, em- Kanavel, A. B.: The Transplantation of ployed. Free Flaps of Fat. Surg. Gyn. and Obstet., Case 13. Figs. 43 and 44 are X-rays Aug., 1916, v. 23, p. 163-176. of a resected elbow joint. The joint was Kirschner. M.: Ueber Freie Autoplastische tuberculous and ankylosed in partial Sehen-und Fascientransplantation. Beitr. zur. flexion. Both humerous, radius and Klin. Chirurg., 1909, v. 65, p. 472-503. ulna were resected, with interposition Kleinschmidt, O.: Die Freie Autoplastische cf fascia and fat. The illustrations Fascien-transplantation (with 163 references), show the arm extended and flexed and Ergebn'd, Chir. und Ort' op., 1914, v. 8, p. 207- the amount of motion possible. 273. 22 SOUTHERN MEDICINE AND SURGERY January, 1922. Lewis, Dean: Transplantation of Tissue, that memorable spot where Jefferson Lancet, Clinic, April 1, 1916, v. 115, p. 296- Davis took the oath as President of the 306. Confederate States of America. But a Marshall, V. F.: Autogenous Fascial Trans- change had taken place since my last plantation with Report of Three Cases. Surg, visit. In front of the brass star let into Gyn. and Obstet., 1914, v, 19, p. 114. the pavement of the portico of the Cap- Marshall, V. F.: The Transplantation of itol which marks that historic event, I Fat and Fascia Flaps in Surgery (with refer- found a new star,a gold star placed there ences). Am. Jour, of Surg., Jul}', 1916. to commemorate the loyal and interpid McArthur, L. L.: Transplantation of Tis- sons of Alabama who gave their last sues. Internat. Clinics, 1913, 23s, v. 1, p. 146. full measure of devotion in the defense McWilliams, C. A.: Bone Grafting. Collec- of democracy and civilization in the tive Review. Surg. Gyn. and Obstet., 1916, Great World War. Is not that symbolic XXII, No. 1. of a greater unity, far beyond even the Mueller, Paul: Deckung von Schaedel-de- imaginings of the framers of our con- fecten aus dem Sternum. Zentralbl. f. Chir- stitution, a unity which now binds over urg., 1915, V. 11, p. 409. forty-eight States into a great and pow- Neuhof, H.: Fascia Transplants. Med. Rec- erful nation? ord, March 25, 1916, v. 89, p. 580. The selection of a subject for your Shaw, H. A.: Fascia Transplantation with consideration involved some difficulty, a Report of an Unusual Case. Northwest The high character of the personnel of Medicine, 1915, v. 7, p. 388. your membership is widely recognized. Von Eberts, E. M., and Hill, W. H. P.: Free There is no purely scientific question Transplantation of Fascia (with references), connected with medicine or surgery, Surg. Gyn. and Obstet., March, 1914, v. 18, which I would be able to discuss in a p. 318. manner deserving of your considera- ^ tion. The rapid development and pres- ent high efficiency of your public health THE SOCIAL RESPONSIBILITIES OF organization is equally well known. Un- MODERN MEDICINE* c^er your State Health Oificer, whose services as a member of the Council on Frederick R. Green, A.M., M.D. Health and Public Instruction have Secretary Council on Health and Public ^^^^ invaluable to OUr national body, Instruction, American Medical Association, y^^j. g^-^^-g Yiaa attained an enviable Permit me to first express my thanks reputation in public health. In this and appreciation of the invitation ex- field as well, I have nothing to offer tended to me through the officers of that would be worthy of this occasion, your association to attend this meeting. The discussion of any question con- The pleasure of meeting a session of nected with either scientific medicine or the Medical Association of the State of public health was therefore barred. North Carolina is one which I have long But there is another field of effort, anticipated. As was so well and elo- distinct, yet closely allied to these two quently described by your president, great subjects, which has during the this morning, the development of our last generation been slowly, almost im- State association during the last twen- perceptably developing before our eyes, ty years has been a source of gratifica- It is that of social medicine, the influ- tion to all those interested in seeing the ence of and the relation of modern scien- medical profession of our nation become tific medicine to social conditions. Un- a compact and efficient body. I had the thought of and unrecognized until re- pleasure last week of attending the cently, it has now assumed an import- meeting of the Medical Association of ance both to physicians and the public your sister State of Alabama. I had which can no longer be ignored. It is not been in Montgomery since 1916. On to this field that I invite your attention, the last day of my visit, I went as I Your President this morning in his always do to the Capitol Building to brilliant address, did me the great hon- view the relics of the earlier years of or of quoting a few sentences from a our nation's history and to stand on previous paper of mine along similar lines. Not suspecting that any modest *Read before the North Carolina Medical efforts of mine had attracted any COn- Society at the Pinehurst meeting, April 26-28, siderable attention, I have used some 1921. of this material on some points which January, 1922. ORIGINAL COMMUNICATIONS 23 I conceive to be fundamental in discuss- ing any of our problems, in laying the foundation for the argument I am about to present. For this unavoidable repe- tition I ask your patience and forbear- ance. The problems of social medicine are peculiar to the present generation. Their development is due to the change that has taken place in the relations between physicians and the public. Up to the middle of the last century, medi- cal practice was individual. No one con- sulted a doctor until afflicted with some specific disorder. The only interest that the physician had in the patient was a personal one. Little was known regard- ing the cause of disease, the method of its transmission, or the means for its prevention. If a physician was called to see a patient suffering from typhoid fever, he treated the patient until he recovered or died. There was no way of knowing how the patient had acquir- ed the disease or how any other indi- vidual could acquire the disease from him. The physician had no responsi- bility to the community, since there was no act of his, the performance or omission of which could in any way af- fect society, either favorably or unfa- vorably. AH that he could do was to care for his individual patient and. so far as possible, in the case of those dis- eases which experience had shown to be infectious, to prevent others from contracting it. As Sir George Newman, the Chief Medical Officer of the British Ministry of Health, says, up to 1850 the medical profession had no public or so- cial functions or responsibilites except the enforcement of such crude methods of quarantine as had been developed through experience. Public Health Work up to the last half century was largely accidental and empirical. As a result, the instincts, training, methods and traditions of the medical profession for centuries past were en- tirely individualistic and were centered on the individual treatment of individ- ual patients. This was the full duty of the physician. But today an entirely different situation exists. Modern med- icine has a social value as great, if not greater, than its individual importance. The development of the natural sciences during the nineteenth century has in- creased our knowledge of diseases and their prevention more rapidly during the last fifty years, than in the preced- ing 1,800 years of the Christian Era. The development of preventive medicine since 1870 is too well known to need re- counting. Today, if a physician is called to see a patient and makes a diagnosis of typhoid fever, while he will naturally do everything possible to promote the comfort and recovery of his patient, yet the determination of the source of the disease and the prevention of the devel- opment of other cases from the initial case as a focus, i. e., the social aspects of the problem, are of as great if not greater importance than the treatment of the individual patient. This becomes increasingly true as the disease in- creases in rarity and severity. Suppose a single case of bubonic plague were discovered tomorrow in New York City. The correctness of the diagnosis of this single case would affect directly or in- (irtctly every man, woman and child of the millions in New York and of the many millions in the eastern half of the nation. A single case of Asiatic cholera unrecognized in one of our seaports might easily change the currents of trade and aflfect millions of dollars of capital and innumerable human beings. Modern scientific medicine is today one of the most vitally important and indis- pensable factors in modern life and we have as yet only seen the beginning. We cannot now appreciate nor realize the possible benefits which our present and future knowledge of diseases and their control will have on the well being and happiness of the human race. But while for half a century our knowledge, as Tennyson says has "grown from more to more," our pro- fessional habits have remained the same. While the social value of medi- cal services is now equal to, if not greater than the value of medical ser- vices to the individual, the medical pro- fession is, in its methods, as individual- istic today as it was fifty years ago and as it has been for the last five hundred years. In spite of the rapid develop- ment of public health administration as a function of municipal. State and na- tional governments and the constantly increasing demand for properly trained and qualified men to serve in official positions, medical students are still trained almost exclusively for the treat- ment of individual pitients. Practical- ly nothing is taught regarding social medicine. If, after graiuation, a phy- sician has an opportunity to take up 24 SOUTHERN MEDICINE AND SURGERY January, 1922. public health work, he is forced to get his training at the expense of the com- munity after he has been appointed to office. It is only in the last few years that any differentiation has been under- taken between the training necessary for individual practice and that requir- ed of a man who desired to devote him- self to the service of the community or the State. What is true of our medical colleges is also true of our medical societies. Papers on Public Health questions or on social and economic problems are read to a handful of listeners, while the majority of the members flock to some surgical amphitheater to see a surgeon operate on an individual gall bladder, or to listen to papers on the diagnosis and treatment of individual patients. Ques- tions of public policy and legislation, involving the welfare of an entire State, arouse little general interest and are left to a small group of public spirited physicians. Our professional standards are based on the same methods of val- uation. An individual's standing or success in the profession is estimated largely by the number of patients he has seen, the number of clinical cases he has reported or the number of oper- ations he has performed. So long as the profession was limited entirely to individual services, these were the nat- ural standards. Today these standards are obsolete and in need of revision. If it be argued that in the develop- ment of social medicine in so far as it has gone, the physician has contributed his full share of services, often at con- siderable sacrifice to himself, it can only be replied that this is perfectly true and that as a health officer or member of a local or State board of health at a ridiculously small and inadequate sal- ary, or as an attending physician or surgeon to a public institution or free clinic, the great majority of physicians give valuable service worth large sums of money. But it is at the same time equally true that these contributions, magnificently generous as they are, have been contributed by the physician as an individual rather than as a pro- fessional participation in a definite so- cial program. The explanation of this apparently paradoxical situation lies in the fact that today, as for centuries past, the physician makes his living by charging individual patients for individual ser- vices and so long as individual services are the principal source of income of the majority of physicians, there natur- ally will his chief interest lie. While the development of scientific knowledge in the last fifty years has produced an entirely different conception of the re- lation of disease to society, of the duty of society to the individual and of the individual to society in the control and prevention of disease, the economic re- lation of physicians, both as individuals and as a body, to their patients is still practically the same individualistic re- lation that it has been for hundreds of years past. The medical student of to- day still gives the greater part, if not all of his time to the study of disease as an individual phenomenon, while the practicing physician gives the bulk of his time and all of his interest to the treatment of individual patients. It is absolutely essential that physicians recognize the fact that the treatment of diseases of the community and of so- cial conditions which produce disease and impair efficiency are just as much functions of the medical profession as are diseases of the individual ; and that they endeavor to qualify for the same services in the social field that they have so magnificently performed and are now performing in the individual field. If we fail to do so then we must ex- pect to see this field taken over by non- medical workers. This has actually oc- curred in the last few years in social welfare organizations, made up almost entirely of men and women without medical knowledge and in many cases without any scientific training. While an effort has been made to put their theories and practice on a sound basis, the subject is, as yet too new, the data too incomplete and the workers as a rule too little trained to entitle social welfare to recognition as a science. Yet there has been no lack of suggestions from this class of workers as to the remedies which they consider appropri- ate for existing social conditions. To attempt to discuss all of the schemes which have been proposed for the improvement of health through so- cial methods would be impossible. The two which have so far aroused the most interest and discussion are Compulsory Health Insurance and Rural Health Centers. As remedies for our supposed January, 1922 ORIGINAL COMMUNICATIONS 25 social ills they require careful consid- Contrary to general expectation, it was eration. only introduced in a single State legis- Compulsory, State supervised, Indus- lature during the last winter, that of trial insurance, social or health insur- New York, where it has so far remained ance as it is variously called, originated in committee. in Germany in 1883. Responsibility for Let us now ask what is this proposed it is generally attributed to Bismark, plan, stated in its simplest terms. The at that time Chancellor of the German standard bill drafted by the American Empire. Various forms of State Insur- Association for Labor Legislation pro- ance, partial or complete, compulsory vides that all employees earning less or voluntary, have in the last thirty- than $100.00 per month shall be entitled five years been adopted in many Euro- to medical, surgical, hospital and nurs- pean countries. To discuss the details ing care, dental treatment, maternity, of this movement in each country is benefits, cash benefits, and funeral al- impossible within the limits of this lowances. These services are to be paid paper. In this country, the subject was for out of a fund of which two-fifths first taken up by the American Asso- are to be contributed by the employee elation for Labor Legislation, which in the form of compulsory payments of had previously been active in securing a certain percentage of his wages, vari- the passage of workmen's compen.sation ously estimated at from 3 to 71/2 per laws in forty-two States. In December, cent, two-fifths are contributed by the 1912, it organized its social insurance employer in the form of compulsory committee, which in 1914 prepared a payments of about the same percentage tentative draft of a health insurance of his pay roll and the remaining fifth act. This was introduced in Massachu- is contributed by the State. This fund setts. New York and New Jersey. In is to be administered by a local board 1917, the bill was introduced in twelve for each group of 5,000 employees to other State legislatures. None of these be composed of an equal number of rep- fifteen States adopted the bill. Eight resentatives of employers and employ- of them, California, Mas.sachusetts, New ees, all the local boards to be under a Jersey, Connecticutt, Illinois, Ohio, State commission, which determines the Pennsylvania and Wisconsin, appointed conditions of medical treatment, terms commissions to investigate the subject, of compensation to physicians, etc. In Massachusetts and California, two Details vary in different bills, but do successive commissions were appointed, not afl'ect the principles involved. The making in all ten official bodies, which maximum annual income as fixed by the have made surveys, collected evidence, British law was approximately $800.00 held hearings and issued reports on this a year. That is, only employed persons question. In New York, a reconstruc- whose gross annual income was $800.00 tion commission, appointed by the Gov- or less, came under the compulsory pro- ernor, also considered it. In Massachu- visions of the law. This has since been setts, the first commission reported in raised to $1,200.00. In the Model Bill favor of compulsory health insurance drafted by the American Association and the second commission reported ad- for Labor Legislation, the maximum ver.-ely. In California, both commis- amount is $100.00 a month. In the pres- sions reported in favor of the plan, but ent New York Bill, the limit is $600.00 on a referendum to amend the State con- per year. The proportionate amounts stitution to permit the establishment of to be contributed by the three parties compulsory State health insurance it also vary in different bills. The amount was defeated by a vote of 358, 324 to contributed by each employee is fixed 138, 858. In New Jersey and Ohio, the by a sliding scale in accordance with commission reported favorably. In Con- which the amount contributed by the nccticutt, Wisconsin and Illinois, the employee decreased and that contribut- majority of the commission reported ed by the employer increased as the against it. In Pennsylvania, the com- weekly earnings decreased in amount, mission recommended further study Employees receiving less than $5.00 a and investigation. In New York, the week pay nothing, the employer pays Governor's commission reported favor- 80 per cent and the State 20 per cent, ably but the bill failed to pass. Up to Medical and surgical attendance is pro- the present time it has been introduced vided either by the appointment of cer- in fifteen States and passed in none, tain physicians or by the creation of a SOUTHERN MEDICINE AND SURGERY January, 1922. panel or list of physicians in each dis- trict willing to care for those insured. Proposals for the compensation of phy- sician differ. The payment to each phy- sician of a fixed salary, division among all the physicians on the panel of the amount appropriated for medical and surgical services for the district and a capitation system by which each physi- cian is paid in accordance with the num- ber of persons treated or the amount of work done during the year, are among the methods proposed. Such is the plan in its briefest terms. Endless discussion has taken place re- garding details with the result that the fundamental issues have been lost sight of. What are the arguments in favor of it? The brief on the model bill prepared by the American Association for Labor Legislation makes the following claims : There is a disproportionately large amount of sickness among the employ- ed. This causes immediate loss of time and wages and results eventually in in- capacity and poverty. There are as nearly as can be estimated, 3,000,000 persons in the United States sick at any one time. Each of the 30,000,000 wage earners loses approximately nine days a year through illness. The resultant an- nual wage loss amounts to half a billion dollars. The wages paid American workingmen are inadequate to enable them to meet the expense of sickness and to bear the losses consequent on sickness and incapacity. It is, there- fore, it is claimed, necessary to distrib-- ute this burden among three parties, viz., the employee, the employer and the State. The objects of the proposed plan are, primarily two, viz., to reduce to a minimum the amount of time lost by workmen through sickness and to divide between the State and the em- ployer 60 per cent of the cost of the illness of employees, leaving 40 per cent for them to carry as their share. It would be interesting if time per- mitted to discuss in detail the evidence produced by the advocates of social in- surance in support of their proposition. It can only be pointed out here that the arguments in favor of the plan rests on estimates or opinions and not on facts. The evidence is not "overwhelming," neither does it clearly indicate the need for social insurance as claimed by its advocates. On the contrary, the evi- dence is fragmentary, incomplete and inconvincing and many of the conclu- sions drawn are not justified by the facts. There are no figures in exist- ence, showing the death rate in the United States from diflTerent causes or in different social and industrial classes, the amount of sickness in the United States for any given period or class, the average income of workmen in the Unit- ed States or the average amount of time lost by workmen through illness. State- ments made by advocates of the plan are, in the main, based on studies of small groups, the conclusions drawn from three groups being applied at pro- portional rates to the entire population. Such methods are clearly fallacious. There are no reasonably complete or convincing data which would justify the sweeping generalizations made by the advocates of the scheme. The only way in which convincing evidence can be secured is by a survey made not to secure evidence to support a precon- ceived theory, but to obtain facts as to existing conditions as a basis for what- ever constructive action may be found necessary. Such a survey has not yet been made in any State. Let us now examine the plan to de- termine what it is not. In the first place it is not insurance. The essential principle of insurance is the distribu- tion of loss from any cause among a large number of persons subject to the same risk, so that the loss of one will be borne proportionately^ by all. For example, 100,000 men owning homes, either by mutual agreement or by tak- ing out policies under an insurance com- pany, prorate among the entire number any losses that may arise to any one of the number, so that the loss of each one is distributed among the entire group rather than borne by the individ- ual. That is insurance. The proposed plan is not insurance, since it does not distribute the loss among those exposed to the same risk, but brings in two par- ties in no ways sharers of the risk, viz., the employer and the State. If the pro- posed plan provided for distribution of the entire cost of illness of employees among themselves, either mutually or through a supervising corporation or the State, then it would be insurance. As it is, it !,■ simply a method of tax- ing all the citizens of the State, either directly or indirectly, in order to main- tain the productive efficiency of a pai't of the population. All the cost will ul- January. 1922. ORIGINAL COMMUNICATIONS 27 timately come on the consumer. Neither those who are employed and who are the employee or the employer as such drawing wages. Those employed at the will bear any part of the expense, time such a law would go into effect What would happen if such a plan were and those incapable of supporting them- adopted in any State? The workmen selves, are in no way provided for un- finding that a certain amount was de- der such a plan and would be cared for ducted from his wages each week would through voluntary philanthropy or by immediately demand that his wages be State charitable institutions, as at pres- increased enough to make good this ent. deficit. This increased wage would be In the fourth place, it is unsuited to added to the operating expense of the social, economic and political conditions plant. The employer would hardly be in this country. It is undemocratic in expected to pay his assessment out of that it substitutes governmental care his profits. He would add his share to for personal responsibility and creates a the operating expense account. So that definite class of employees. In Euro- the cost of production and ultimately pean countries classes are fixed and sta- the cost of the product to the consumer tionary. A man is born into a wage would be increased by the addition of earning family, he becomes a wage whatever amount the employee and the earner and generally remains one. In employer are compelled to pay and this country we have no such class dis- would be paid by the consumer as an tinctions. The employee of today is the indirect tax, as a part of the price of employer of tomorrow and the member the commodity. The one-fifth contrib- of the leisure class the day after. He uted by the State could only be paid out is not only able and willing, but eager of money secured by taxation. The pro- to bear his own responsibilities, to as- posed plan, therefore, is not insurance sume the burden of his own mistakes at all, but is simply a plan for provid- and misfortunes and to reap the result ing medical, surgical and hospital care of his own enterprise and energy. He for employed persons in order to in- does not need nor desire governmental crease the industrial output and so ben- supervision. efit a portion of the population at the When carefully analyzed, the pro- expense of the entire citizen body, posed plan is seen to rest on four prop- through direct and indirect taxation. ositions, all of which must be proven in In the second place, the proposed plan order to establish a case. These are: is not health insurance. The object is 1. There is a disproportionate amount rot the maintenance of health, but the of sickness among employed persons; maintenance of productive efficiency. It causing financial loss, incapacity and is neither a medical nor public health poverty greater in proportion than that proposition. It is purely an economic sustained by the average person and re- n:easure, intended to maintain the effi- quiring special methods of relief. Until ciency of the employee and the product- this is proven there is no reason for iveness of the industrial plant at the special laws for employees, highest possible point. There is no evi- 2. The financial burden caused by c'ence that the proposed plan would sickness is heavier than the average have any public health value. The best employee is able to bear. Until this is and most reliable information from proven there is no reason to assume England is that after ten years trial in that he cannot carry his own burden, that country it has had no effect on 3. Present methods of promoting public health. The term health insur- public health and controlling diseases p.nce, tnerefore. is a misnomer. Instead, are not adequate. Until this is proven it should be called taxation for the in- there is no need of devising any new crease of industrial production. plan. In the third place, contrary to popu- 4. Compulsory State supervised sick- lar conception, the proposed plan is not ness insurance is the best remedy for intended for the relief of poverty and this condition. Until this is proven it is unemployment. In England, which has possible that some other remedy may probably the most elaborate system of be better. poor relief laws of any country, the The burden of proving these four operation of the poor laws has not been propositions lies with the advocates of altered by the adoption of social insur- social insurance. No one of them has ance. The proposed plan only cares for yet been proven. Neither is there at 28 SOUTHERN MEDICINE AND SURGERY January. 1922. present any conclusive evidence or any through trades unions, benefit associa- mass of statistics or data by which any tions, etc., for their own protection, one of them can be proven. It is not All of these are possible alternatives known how much illness or incapacit:- to compulsory insurance involving the exists, either among employed persons development of methods already in or among any other class of our pop- operation. Naturally, existing remedies ulation. It is not known what is the must be considered and tried before a average wage. It is not known whether new and untried scheme is adopted, the burden of illness is or is not heav- Just as the surgeon would consider ier than the average employee can bear every alternative before advising a rad- without assistance. It is not known ical operation, so the inadequacy of ex- whether existing agencies are adequate isting methods must be proven before or not. Statement as to the number of taking up any new and experimental persons sick in the United States at any scheme. one time, among wage earners, or any The attitude of the organized medi- other class, or among the population as cal profession on this question has beeri a whole, or as to the amount of time officially determined. Tne American or money lost through sickness are esti- Medical Association at the New Orleans mates, in many cases are mere guesses, session in April, 1920, adopted by a based on generalizations from incom- practically unanimous vote a resolution plete and inadequate data and not on declaring its opposition to any plan of facts. compulsory contributory insurance Of the four essential propositions on against illness or any other plan of which the proposed plan rests, the first compulsory insurance, provided, con- three cannot be proven, owing to in- trolled or regulated by any State or the sufficient knowledge. But even if it Federal Government. A number of could be shown that employees as a State associations have adopted similar class are suffering from an undue resolutions. The organized medical pro- amount of illness, that the financial cost fessicn is, therefore, unqualifiedly op- is greater than they can bear without posed to compulsory State health insur- assistance and that the present method ance. for remedying this situation are inade- This action of the House of Delegates quate, it still remains to be proven that was unanimously endorsed by the Coun- the plan proposed is the best remedy, cil on Health and Public Instruction, a The claim that health insurance is the result to which the secretary of your best remedy for existing social ills is a State Board of Health, as a member of pure assumption. At least five alterna- Council, who had been from the begin- tives must first be considered. They ning strongly opposed to Health Insur- are: ' ance, largely contributed. 1. An increase in the wages paid to The second plan for improving the the employed, so that each one will be conditions of medical service is gener- able to bear his own burdens. ally known under the name of Health 2. The development of State, munici- Centers and is an effort to concentrate pal and local health agencies to a point in one institution in each county or where preventable diseases will be re- rural community, all of the local forces duced to a minimum and the burden on for better health conditions. Two forms the individual limited by reducing the of such an organization have so far amount of sickness. been proposed. The first is that pro- 3. The development of voluntary posed by the American Red Cross, fol- thrift and saving habits among em- lowing the close of the war. Before the ployees to a point where through in- war, the Red Cross was a limited semi- creased thrift and foresight they may official organization for the temporary be able to provide for their own emer- relief of communities in times of dis- gencies. aster. During the war, it developed 4. The development of voluntary in- into an enormous popular organization dustrial insurance on the part of em- of 22,000,000 members. Its work dur- ployees and employers in industrial cor- ing the war, both in this country and in porations and groups. Europe, is deserving of the highest 5. The development on the part of praise. After the armistice, however, it wage earners and employees themselves was one of the few war time organiza- of voluntary assessments and benefits tions which did not revert to its peace January. 1922 ORIGINAL COMMUNICATIONS 29 time status, on the contrary it has en- deavored to retain its war time mem- bership and public support. In order to do this it was necessary to formulate and nresent plans for peace time activi- t'es which would be commensurate in importance with the size of the mem- bership and the amount of its income. Two main projects were announced, rural health centers and public health nursing. The official announcement is- sued by the American Red Cross, Sep- tember 25, 1919. defines a Health Cen- ter as a physical headquarters for the public health work of the community. It suggests as possible features, a tu- berculosis clinic ; a child welfare bu- reau ; community headquarters with reading and rest rooms ; headquarters for the district nurse, baby health con- tests; social hygiene clinical and edu- cational work ; industrial health clinics and instruction on the prevention of ac- cidents and industrial illness ; dental and general clinics, etc. The Red Cross program is as yet too vague to be of value as a detailed work- ing plan. Although the plans for Red Cross Health Centers were announced two ye?rs ago, they have not been adcn'ed to any extent, neither have they mar'e any appreciable impression on the existing situation. The other proposed plan for health centers originated in New York, largely as a substitute for Health Insurance. The Sage-Machold Bill, intro(;luced in the New York Legislature in March, 1920, divided the State into health dis- tricts and provided for a health center in each district. This bill did not pass. The Robinson-Moore Rill now before the New York Legislature, is practically the same bill as far as health centers are concerned, but omits the provisions re- garding health districts. The object of the bill is to provide the residents of rural districts and all others who can- not otherwise secure such privileges with adequate medical treatment, hos- pital and dispensary facilities and nurse's care ; to assist local physicians by providing laboratory and other ser- vice and to improve the public health by authorizing a county or city to cre- ate and maintain health centers. The Board of Supervisors in any county is authorized to establish one or more such health centers. City centers may be established by municipal authorities. The centers are to include a general hospital with special pavilions for tu- berculosis and other communicable dis- eases, children and maternity cases and mental diseases. There are also to be clinics for out patients, clinical, pa- thological bacteriological, chemical and X-ray laboratories auxiliary to the lab- oratory of the State Department of Health ; public health nursing service ; headquarters for voluntary public health agencies ; medical libraries, fa- cilities for medical inspection and su- pervision of school children and period- ical examination of such inhabitants of the district as may desire it. The Health Center is to be under a Board of Managers, consisting of the County Judge, two practicing physicians, one woman and three other members. All persons residing in the district may avail themselves of the health center facilities. Those who are unable to pay are to be given examination, care and treatment free. Others are to pay such charges as may be fixed by the super- intendent. Each paying patient shall be treated by the physician he selects. Funds are to be derived from charges for patients able to pay, local public funds, gifts, donations and bequests and from State aid. Grants from the State are to include the following: one-half the cost of construction not to exceed $750 a bed; seventy-five cents per day for each free patient ; one-half the cost of installation of each out patient clinic not to exceed $5,000 ; fifty per cent of the cost of free treatment not to exceed an average of 20 cents per treatment; one-half the cost and maintenance for the laboratory, not to exceed $3,000 and $1,500 for the initial installation and equipment of each laboratory. Health Centers are to be inspected and stand- ardized by the State Department of Health and State aid is to be given to those centers which are approved by the State Commissioner of Health. This bill at the same time of writing is be- fore the Finance Committee of the State Legislature. Of the two remedies proposed, health insurance is economically, socially and scientifically unsound, while the health center idea is not as yet sufficiently de- veloped to admit of definite criticism as a national remedy. It will, of course, readily be conceded that in several in- stances locally organized health centers have been successfully conducted. These isolated and sporadic successes, how- 30 SOUTHERN MEDICINE AND SURGERY January, 1922. ever, do not form a sufficient justifica- edge of social conditions necessary for tion of the plan as a solution of na- accurate diagnosis of social ills, nor will tional social problems. such a diagnosis be possible until we While this disposes of the specific exert the same energy, ability, industry questions of Health Insurance and and perseverance in the study of social health centers a larger problem at once ills that the medical men of our own presents itself. Does the rendering of and previous generations have shown an adverse verdict on these two pro- in investigating the disease of the in- posals constitute the whole duty of phy- dividual. But the assumption of this sicians? Let us apply the same situa- task is an assertion of our belief that tion to the more familiar field of pri- the study and treatment of social ills vate practice. Suppose any one of us are just as much functions of the mod- were called as a consultant in the case ern nhysicians as are the diagnosis and of an individual patient. After careful treatment of the ills of the individual, examination of the patient, we find that Are we as physicians willing to take both the diagnosis and the treatment this • position and abide by its conse- are wrong. Is our full duty as a con- quences? sultant performed when we have stated It is important that physicians should these conclusions to the patient or to understand clearly the significance of his friends? Under such circumstances the present agitation for social reforms would we not immediately be asked to in the health field. To regard this move- furnish the correct diagnosis in place ment as an isolated and single phenom- of the erroneous one and to supply a enon would be a serious error. On the proper method of treatment as a sub- contrary it is due to a series of causes stitute for the one we have condemned? which spring from the same sources as And would we not all admit if we re- the development of scientific medicine, fused to do so, there was no alternative The medical profession itself through remaining but to confess that the case its labors and progress is very largely was beyond our ability and knowledge responsible for the present situation, and to withdraw and give place to a For fifty years we have been so busy more capable consultant. extending our knowledge that we have In the case under discussion the pa- not had time to adjust our methods to tient IS the social body. That it is suf- conform to changing conditions. While fermg from certain ills is probably not we possess scientific knowledge which questioned by any one. The exact na- enables us to render service of greater ture and extent of these ills, in other value than any other professional group words, the diagnosis, is the question at can offer, we have continued to do busi- issue. Until an exact diagnosis is made, ness on "the old basis of so many dollars any proposed method of treatment must for so many calls on the individual pa- necessarily be empirical rather than tient. Yet the medical service which scientific. We have questioned the can be rendered and which in the fu- views of those who claim to be compe- ture must be rendered to the commu- tent and qualified to diagnose and pre- nitv bv physicians are of far greater scribe for our social ills. We have op- value than anv service which we can posed the treatment which they have render to the individual. Medical ser- prescribed as unscientific and inade- vices have grown in value until under quate. Does not this situation consti- present methods, modern, up-to-date tute a direct and unavoidable challenge medical attention is beyond the reach to the medical profession, either to fur- of the majoritv of persons unless they nish a correct remedy for such ills as secure it through charity. Health In- may be demonstrated or to admit that surance is only one of the schemes pro- the case lies outside of our province posed whereby adequate medical ser- and to withdraw in favor of a better vices can be put in within the reach of qualified authority? the average workman. The fact that I think we will all agree that both this particular plan is economically un- the making of a diagnosis and the pre- sound and that it probably would be in- scribing of the treatment of the dis- effective in operation does not relieve us eases of society are at present beyond of the immediate necessity of devising the ability and knowledge of any one some method by which adequate medi- man, either physician or layman. We cal services can be made available for are at present without the exact knowl- every individual needing them. January, 1922. ORIGINAL COMMUNICATIONS 31 The proponents of the proposed plan, I assume there is no difference of instead of first studying the situation opinion as to the answer to this ques- in this country and devising a plan suit- ticn. The medical profession owes it to p.ble to existing conditions, endeavored society as well as to the individual to to transplant entire from Germany by render the best service and to do the the way of England a plan unsuited to best work of which it is capable. It is this country and out of harmony with inconceivable that the highest type of our social institutions and economic con- medical service, whether individual or ditions. But condemnation and defeat social, shall be rendered by any other of health insurance brings us no nearer than scientifically trained men. ' But if the solution of the real problems than physicians are going to assume this re- we were before. There still remains sponsibility, especially if we are going the need, as im.perative as ever, of re- to demand control of this field, as we modeling the economic methods of prac- have of the field of the treatment of tice now existing in the medical pro- individual ills, then we must qualify for fession and of substituting for the social leadership just as thoroughly as method of individual services to indi- we are now qualifying for individual vidual patients some plan whereby each services. individual as a part of his social right If we are going to assume leadership, will secure every protection for his then we must have a definite policy and health and well being that modern med- this policy must be based on knowledge ical knowledge can give him. The ef- and not on prejudice and selfish inter- forts for the adoption of health insur- ests. If the medical profession is to ance should be recognized as the be- undertake responsibility for social ser- ginning of an effort to readjust profes- vice as a part of its professional func- sional methods to social needs. tions, then social medicine and its prob- In the discussion of this method there lems must be studied and discussed in pre as always three distinct groups: our medical organizations and medical First, the conservatives who desire only publications as carefully as the prob- that things shall remain as they are; lems of individual medicine. If social second, the radicals who look forward medicine is to be one of the functions with erger vision and often without ac- of the medical profession of the future, curate discrimination to what th?y horc then the medical student of the future will be better conditions and who favor must be given broad and adequate in- any proposed change in the existing struction regarding its problems. He status; and third, the mass of the med- must be taught social anatomy, pathol- ical profession who have accepted con- ogy, diagnosis and treatment as thor- di tions as they found them and have oughly as he is now taught the diagno- made the best of them, who are willing sis and treatment of individual diseases, to adopt new methods if their value can We must begin in our medical schools be demonstrated, who are neither wed- to teach the medical student social med- ded to the past as are the conservatives, icine and to develop in the doctor of the nor plunging rashly into the future as future an instinct and a capacity for are the radicals. I take it that 75 per social leadership. cent at least of this audience belongs to The issue is plainly before us. Shall the third class. To you. therefore, I we adhere to the methods and practices wish to submit what is to my mind the of the past until we are forced to aban- most important and fundamental ques- don them, or shall we broaden our meth- tion in the whole discussion. Briefly ods to keep pace with the ever widen- stated, it is this: Is social medicine a ing bounds of scientific knowledge. The function of physicians? Is the physi- question must be answered by those cian of the future going to restrict him- who are practicing medicine today, for self to the treatment of individual pa- in your hands lies the future of scien- tients as he has in the past, or is he tific medicine. going to assume the responsibility for the treatment of society and of human- ity in the mass as well as of the indi- The next annual meeting of the Tri- vidual. If he is, then he must quality State Medical Association will be held himself for this work. If he is not, February 22-23, 1922, at Norfolk, Va., then he cannot complain if others take with headquarters at the Monticello up the work which he refuses to do. Hotel. 32 SOUTHERN MEDiCINE AND SURGERY January, 1922. ARMISTICE DAY ADDRESS* by their ancestors. We are not alone in our grief and John Wesley Long, formerly Lt. Col. M. C, sense of gratitude for what this day U. S. A. stands for. At this same hour the Pres- dent of the United States is marching Ih'. Commander of the Henry Burtner at the head of a distinguished proces- Post, Fellow Ex-Service Men and sion in the National Capital, while all Nurses, Ladies and Gentlemen: America, from Alaska's frozen zone to As vou already know President Hard- 0"^ possessions in the Carribean Sea, ing has requested that at high noon to- stands with uncovered head to do honor day everything from the wheels of com- to the men of the allied Armies who by merce to the least activity of the peo- their sacrifice made this day possible, pie shall stop and that every one shall First, I would speak a word to and stand in silent Drayer for two minutes, of the living. Two years ago I was You will be notified of the time by the »sked to deliver the memorial address to tolling of the bells of the city. As your the Confederate Veterans of Guilford ranking officer, I desire that every ex- County. As I spoke to those old war- service man and woman shall at that ^^o^s '^ho followed Lee and Jackson, I moment come promptly to attention and realized that they were living largely m maintain that attitude during the pray- the past. I reviewed with them some er. And we will appreciate it if the o^ their unsurpassed deeds of valor and whole audience joins with us in this act endurance and the part they had played of devotion by standing. m the history of our country. Today, Armistice Day will always be consid- I address young men and women, to the ered as a holy day in America. It ranks ^^^^ °^ ^^ ^^^."J^ ' J^^: ^« ^^^^^ ^.^^ with the Fourth of July and is second in S^'^J, ^^""If "^^ Y""^"^" their names in m- importance only to that day upon which ^^^'^^^ characters upon the most glo- the Saviour of mankind was born, '^^l ^^^^ . ^ military history. And Therefore, it is appropriate that we eel- '""^f '^ ^"^^^ ^' important, the men ebrate the occasion with parades, mimic ^"^ ^°T" 1"^°", "^^'T ^^t.^ ^"^1!''!u''^ air battles and addresses commemorat- °^^ ^^1!"^^^ ^^1^^}^ ''^f\f- For whether ing the deeds of our heroic dead. Inci- we will or not all public questions for dentally, it seems to me that there could the next generation shall be determined without the consent of the men and be no more fitting place in which to hold this part of the service than in this women who wore the uniform together magnificent temple of justice. ,T^^ those who stayed at home and by xxr , , , , ,, their activities made it possible for them We have numerous precedents, both to go. If these soldier boys, above all modern and ancient, for celebrating the others, were judged best fitted to carry victories of war and honoring our fallen our flag and defend our Democratic fi!''°f;v. "^^; '',^'' h^^"^^^^ ye^^s ^^o form of government in time of war the Athenians held similar ceremonies, ^ven upon foreign soil; they are fully They gathered the bones of their men ^s capable of upholding the glory of the slam in battle placed them m caskets stars and Stripes and maintaining the decorated with flowers and marched prestige of our institutions in time of with these sacred relics at the head of peace. If the Legionaires believe the the column. For those whom bones ex-service personnel should have a bo- could not be identified an empty casket ^us, by the Eternal they shall have it Similarly decorated was given the posi- sooner or later; because, forsooth, they tion of honor, thus setting a pattern for ^nd their friends are the government, the present day beautiful custom of Don't let us forget that this government honoring the unknown soldier." Fol- jg by the people and for the people! owing the parade the Greeks stood and As a child I remember the Civil War. istened to the incomparable Pericles de- As a man I took part in the World War. hver an oration the eloquence of which Therefore, I sneak to my comrades in comes ringing down through the ages, arms, and to this great host of their History states that m thus celebrating relatives, friends and admirers. My fel- thej-were simply following a custom set low soldiers, accept the assurance that I deem it a very great honor to be =^DeIivered before the American Legionaires your mouth-piece on this memorable of Guilford County occasion. I pledge you always to hold January. 1922 ORIGINAL COMMUNICATIONS 33 aloft the Stars and Stripes under which and cheerfulness with which the men we marched and to defend the fair moved steadily forward into battle ; sec- np.me of the American doughboy and his ond, the fortitude with which the compatriot, the army nurse. If I ever wounded bore their injuries. Never a forget their courage or discount their complaint and scarcely ever a moan, patriotism, as our misrepresentative at They followed Old Glory and were loyal the Court of St. James did, I pray that to it, even in the shadow of death! my tongue shall cleave to the roof of Yea, fellow soldiers, you honor me in my mouth and that my uplifted arm asking me to discharge the responsibili- shall be paralyzed! ties of this hour. And what is of far My confidence in you men is without more reaching significance you place reservation. I was with you from the upon my feeble shoulders and upon my Medical Examining Board to the Train- faltering tongue the sacred duty of an- ing Camp; from the first-aid dressing swering the roll call for those who can station upon the firing line in Northern not speak for themselves. Yea, I must France to the reconstruction hospital answer to this vast assembly for those back here in the States. I was an eye- who paid the supreme sacrifice, as well witness to much of the worjt you did. as for the living. I would that I had Did I not close the Wesley Long Hos- the tongue of a Pericles that I might pital and go with you across the seas? speak words that breathe and live and There is its record! Nine stars to its raciate with that intense spirit of pa- credit and every one more precious than triotism which carried Henry Burtner, diamonds. Did I not stand guard with Alfred Scales, John Paisley, Alfred Wil- you upon the quarter deck of the trans- Hams and Annie Revely and others to port every morning till the breaking of the farthest limits of sacrificial duty! day to see that a submarine did not "Greater love hath no man than this blow us into kingdom come? Did I not that he lay down his life for another." organize Base Hospital No. 65, which To those who are today bowed in sor- was located at Brest, in France, and row I would quote the same Athenian functioned as an evacuating hospital for orator who said on a similar occasion men both going to the front and then "Fortun-jte indeed are they who draw coming back home? Did we not handle for their lot- a death so glorious as that over 40,000 sick and wounded men in which has caused your mourning and that one hospital composed as it was of to whom life has been so exactly meas- a personnel 90 per cent of which were ured as to terminate in the happiness North Carolinians, surgeons, nurses and in which it is passed." enlisted men. many of whom are listen- We are gathered here to celebrate ing to me today. One day we received Armistice Day. We mingle our tears 700 patients, 400 of them being stretch- with those who weep; we recount the er cases. I believe the court would ac- heroic deeds of our noble dead, we look cept me as a "competent witness" to up through our tears and give thanks testify for the American soldiers. to an all wise Providence that their sac- Your activities at Chateau Thierry rifice put a stop to the ravages of war. and Belleau Woods, in the Argonne For- But as a matter of fact do we grasp the est and on the \'erdun front made the full significance of what the armistice world to gasp in astonishment and it meant? I hope we do, but somehow I also made the German High Command have the feeling that only those who to quake in their knees. sent the best they had and they never I was with a division as it went into came back can appreciate the depth and action at Jolney on November 10th, the height and breadth of the armistice. day before the armistice was signed. Sent the boy who, like the brave un- Early in the day I came out of a woods terrified man that he was, bared his upon a cross roads. The sergeant in breast to the murderous fire of the sub- charge of the guard at the place saluted marine, the machine guns and the long and said "The Germans have the range range cannon, not to speak of the nox- of this place and perhaps the Colonel ious gases, bombing airplanes, and the had better move on." Going forward I destructive epidemics that seem to hang came into the thick of the command around every camp both at home and going into action and the wounded men abroad. Only the father and mother being carried to the rear. I was struck whose son and daughter was literally with two things; one the resignation consumed upon the altar of their pa- 34 SOUTHERN MEDICINE AND SURGERY January. 1922. triotism. can comprehend the magnitude Marshal Foch very properly laid down of that historic event which took place for them. on the battle-front in France at the Therefore, friends, that boy whom we eleventh hour of the eleventh day of sent to check the on-coming hordes of tl-'e eleventh month of the year 1918. German barbarians, that stalwart, shiv- Did you ever visualize what the alorous young soldier in whose honor World War meant in actual loss of life we meet today, who fell with his face to and money not to mention the govern- the foe, that hero of the World's War, ments overthrown, the destruction of whether he lies buried in his native soil international trade and the coming of or in Flanders fields, contributed his revolutionary movements like the So- Quota toward stoppmg that awful cata- viet Reds ? Hon. Josephus Daniels, Ex- clysm of war that was rapidly engulf- Secretarv of the Navy, states in a re- ing the world ! cent article that it is estimated that To him should be erpcted a monu- during the four vears of war 7,354,000 ment which shall stand throughout the men were killed ^ in battle or died of ages. To him has already been ascribed wounds, that thirty million men, women a glory that shall shme as long as time pM children have died from disease and shall last. Upon the marble shaft that famine directly as a result of the war; marks his resting place should be chis- fhat six thousand ships, including two eled the living words written upon the hunrh^ed war vessels, were sunk and stones covering the Spartan soldiers that the cost of the war was not less who died at Thermoplae, "Stranger, go than one hundred and fifty billion dol- tell in Lacaedemon that we lie here in lars. obedience to her command." Now, friends, listen to this fact; no one anywhere, outside of Germany per- haps, believed for a moment that the THE PRESIDENT'S ADDRESS. war could possibly end as early as it TENTH DISTRICT MEDICAL AS- did. The wise men in France who knew SOCIATION, MURPHY, N. C, OC- far more about the situation than we TOBER, 1921. -lid were fully persuaded that it would By Dr. F. L. Siler, Franklin, N. c. continue till the summer of 1919, and they feared that it might drag on into There is so much in medicine that is 1920. Suppose the war had lasted for of such vital interest to the laity, so a year or two years longer. What think much that can never be accomplished you would have been the additional loss without the co-operation and the con- in men and money? Even imagination sent of the public, and so much that is f?ils to answer. As early as 1917 the an economic question that we are al- allied countries had exhausted their re- ways glad to have the public understand serve of both men and credit. They that there is no longer any mysteries or wero literally fighting with their backs hidden secrets between the physicians to the wall. When the United States and the laity, that the only part of med- entered the war the Allies rejoiced icine that has a mysterious side to it is greatly because they knew that she that of superstition and the methods could finance the proposition for them employed by the quack to get their as well as for herself. But could she goods before the public. The medical enlist, train, and mobilize the men nee- profession of today is not only studying essary to turn the tide, and do it in the healing art, but has before him that time to save the day ? America, once ancient aphorism that "an ounce of pre- she had declared war, quickly put four vention is worth a pound of cure;" more million men into training and when she restrictions are being made to keep the struck her stride she sent men overseas Public from being imposed upon by at the rate of 300,000 per month. While those unqualified to practice medicine on the heels of the 2,000,000 actually ^"^ greater burdens of responsibility landed in France there were as many ^^^ placed on the profession in safe- more ready and anxious to go guarding the physical well being of the Without question it was the Ameri- community in which we live, so the can doughboy who turned the tide of P^^ctice of medicine is becoming less v,of+i« or,^ fr.^,. A ^-u r- 4. ^ ^"d l^ss a private enterprise and more battle and forced the Germans to accept a public responsibility. If we do not the hard terms of the armistice that recognize the social responsibilities of January, 1922. ORIGINAL COMMUNICATIONS 35 our profession and take the public into it has reached the enormous amount of our confidence in all things pertainin*ections of the State and assist the councillors in build- nig up the county societies, and in mak- ing their work more practical and use- ful." His recent visit to the extreme Western town in North Carolina, Mur- phy, to attend the Tenth District meet- ing was evidence of his active thought- fulness and deep concern to foster the every interest of the organized profes- sion. During the Murphy meeting Dr. Royster gave out an outline of his plans and purposes during his administration arranging for having a program at the next session which would be planned with a view to restricting the activities of "visiting medical statesmen" and em- phasizing the importance of the Caro- lina doctor to the profession, to the so- ciety and to himself. The doctor also plainly expressed his desire to see the for having its own journal and publishing the proceed- ings from month to month rather than a continuance of the present time-hon- ored method of issuing an annual vol- ume which too often appears many months following the State Society's annual meeting. Dr. Royster plans to attend all of the district meetings, and is evincing the liveliest possible inter- est in lending a helping hand at every SOUTHERN MEDICINE AND SURGERY January, 1922. ministration will prove one of the most successful in the State Society's his- tory. J. H. W. Resolved: That the Tenth District Medical Society notes with pleasure the presence and participation in this ses- sion of Dr. Hubert A. Royster, the dis- tinguished surgeon, now the titular head of the State's medical profession, that we appreciate his timely utterances on the purposes and work of the State Medical Society, and do hereby pledge him our earnest efforts to aid in mak- ing his administration and the forth- coming Winston session of the State Medical Society a success. We thank him for his presence, and invite him to come again. NEW INCOME TAX REGULATIONS The following statement is issued by Collector of Internal Revenue Gilliam Grissom for the District of North Caro- lina: The Revenue Act of 1921 contains two new and important provisions, which are the subject of frequent in- quiry. The first relates to the personal exemptions allowed married persons, and the second to the provision requir- ing that a return be made of gross in- come of $5,000 or more. The act provides that a married per- son, living with husband or wife, whose net income for 1921 was $5,000 or less shall be allowed a personal exemption of $2,500. If the net income of such person was over $5,000 the exemption is $2,000. Under the Revenue Act of 1918 the personal exemption allowed a married person was $2,000, regardless of the amount of net income. The nor- mal tax rate remains unchanged, 4 per cent on the first $4,000 of net income above the exemptions and 8 per cent on the remaining net income. In order that an income slightly in excess of $5,000 shall not be subjected to an inordinately disproportionate tax because of the reduction of the exemp- tion to $2,000 thereon, the law provides that such reduction shall not operate to increase the tax, which would be pay- able if the exemption were $2,500, by more than the amount of the net in- come in excess of $5,000. For example, on a net income of $5,- 010, the tax, without this saving clause, would be $120.40, which is 4 per cent on $3,010, the amount of net income less an exemption of $2,000. The actual tax is $110.40, computed as follows: From the net income of $5,010 is deducted S2,500, leaving $2,510, the 4 per cent tax on which amounts to $100.40. To this is added $10, "the amount of net income in excess of $5,000. The personal exemptions allowed married persons apply also to the head of a family, a person who supports in one household one or more relatives by blood, marriage or adoption. Heretofore, a person whose net in- come was less than his exemption ($1,- 000, if single, or $2,000 if married) was not required to file a return. Under the Revenue Act of 1921, if the gross in- come of an individual equalled or ex- ceeded $5,000, or if the combined gross income of a married couple and that of dependent minor children equalled or exceeded $5,000, a return must be filed, regardless of the amount of net in- come. "Net income" is gross income, less certain deductions. The fact that al- lowable deductions from gross income, for business expenses, losses, bad debts, etc., may reduce the net income to an amount below the personal exemptions of $1,000 or $2,000, does not alter the requirement to file a return of gross income, if such gross income equalled or exceeded $5,000. The next annual meeting of the Tri- State Medical Association will be held February 22-23, 1922, at Norfolk, Va., with headquarters at the Monticello Hotel. January. 1922 EDITORIAL " 39 would not be living today but for the SOUTHERN MEDICINE AND SURGERY X^'Z,:! ZJ^'^'S^^":^ Published Monthly by the Panama, would prevent disease. ^.- , L. « ^- II ,„,i r><««»>»w Ot' particular interest to the South is Char otte Medica Journal Company ,, ^ . i. ^ u i i- i.u the first permanent field work ot the M. L TOWNSEND, M. D. i „ . institute, which will be the Gorgas J. c. MONTGOMERY, M. D. \ '^ School of Sanitation to be established CHARLOTTE. N. c. at Tuscaloosa, Ala. For years the South J— p Q^.-- —«=>-.-, , . has suffered because men and women » I < w I" - . - M - ' ' trained to meet the problems of health "Read not to contradict and confute, nor to ^nd sanitation of our Southern coun- believe and take for granted, nor to find talk j ,^, ^^^^ ^^ secured. The Gorgas and discourse, but to weigh and consider. — ^ , , ,, ^, ■, , . .,1 i ^u- Francis Bacon. School ot Sanitation will supply this long-felt need by training county health ■— workers, sanitary engineers and public TO MEMORIALIZE GENERAL ^''we\T all'the oeople in the United GORGAS States have profited most and are still Of tremendous interest to all mem- pro.'iting by the achievements of Gor- bers of the medical profession is the gas. We are also to receive the direct announcement of the complete plans and far-reaching benefits of the estab- for an international memorial to the lishment of the Gorgas School of Sani- memory of the late Major General Wil- tatiun in Alabama. Surely we will take Ham Crawford Gorgas, Surgeon Gen- the lead in honoring one of our own — a eral of the United States Army, con- physician to the world. We cannot for- qucror of yellow fever and malaria in get that Gorgas was a Southern man, Cuba, Panama and many other coun- that his father was our Chief of Ord- tries of the world. narce during the Civil War and later The Board of Directors of the Gorgas president of the University of Alabama. Memorial Institute, which consists of As a matter of gratitude we will do many eminent members of the medical our part in providing funds to make the profession and others of national and m.emorial possible. The memorial means international prominence, has developed more to us than the paying of a worthy with the utmost care and thoroughness tribute to a great man. It means the the plans for an international memo- dawn of a new era of health and sanita- ria! institute to carry on the work of tion, which will make possible the agri- health, sanitation and prevention of dis- cultural and industrial development of ease throughout the ages, protecting the Southern States to an extent never the lives of generations yet unborn, considered possible before. It is, there- Specifically the institute will initiate re- fore, a matter of de2p concern and sin- search into the causes of all diseases cere interest to everyone of us. and the application of the principles of Lack of space forbids the publication preventive medicine and sanitation es- here of the details of the memorial tablished by research. The scientific which has been so carefully developed headquarters of the institute will be by a number of the leading scientists of established in the City of Panama in a the United States. beautiful memorial building containing The Board of Directors is already at thoroughly equipped research laborato- work to raise by popular subscription ries. The site, the building and its com- among all countries of the world an en- plete equipment represent the gift of dowment fund of $6,000,000. The the Republic of Panama, which thus in- South has undertaken to raise $2,000,- itiated the movement to establish the 000 of this amount. Each State is as- Gorgas Memorial Institute. suming its definite share. North Oar- This tribute, not of marble or bronze olina, under the able leadership of Gen- alone but of continuing service to save eral Julian S. C-^rr, has assumed a State human lives, is a particular fitting con- quota of $100,000. ception of the regard held by the people The appeal is not an appeal to the of the entire world for Gorgas. It is a medical profession alone but to all the literal truth that there are hundreds of people of our land— every State and thousands of men and women who every county will be ask^d to take a 40 SOUTHERN MEDICINE AND SURGERY January, 1922. part. No one knows to the same extent as the physicians, the debt which the world owes to General Gorgas and no class of men can know so well the great good which the establishment of the Gorgas School of Sanitation and the In- stitute of Research will accomplish. It will be considered by all of us not a duty but a privilege to contribute when the time comes. But we can be of immediate assistance right now, in the organization of our own cities and counties to make the movement a success. In paying this tribute to Gor- gas we pay the highest tribute within our power to the importance of medical science throughout the entire world. Therefore, the memorial must achieve success. NORFOLK MEETING OF TRI-STATE MEDICAL ASSOCIATION, FEB. 22-23, 1922 Arrangements and plans for the Nor- folk Meeting of the Tri-State Medical Association, to be held at Norfolk, Va., February 22-23, 1922, are progressing most encouragingly, and this promises to be one of the most helpful and in- spiring sessions ever held. The head- quarters will be at the Monticello Ho- tel, which is ample to take care of the comforts of the meetings. Of course, many will not be able to get rooms in the hotel proper but there are a num- ber of other hotels close by, so that all can find accommodation. Better get your reservations in at once, however, in order to avoid confusion and uncer- tainty at the last minute. Again let us call your attention to the fact that at the last meeting the By- Laws were so modified, by an open vote of the general body, that not more than forty papers can be presented at the coming meeting, hence when this num- ber of titles have been received and given a place on the program no others can be accepted. This is a matter over which neither the Secretary nor the President have any control. It is hoped that the program will be filled to the limit and we want you to get your title in at once to the Secretary in order that you may get the place on the program which the merits of your paper deserve. Many papers have already been receiv- ed but there is still some room, so don't delay- until the last moment. In order that the very most good may be obtained by the entire membership from your paper, please do not fail to get some one to discuss it. Select two or three doctors who are interested and familiar with the subject you intend to present and let them have copies of your paper for study and consideration, then give their names to the Secretary. There is no such thing as standing still and if we want this meeting to sur- pass all previous meeting, then we cer- tainly must get busy. This is not an organization of specialists. Its purpose is to serve the general practitioner. These, after all, are the men on whose , houlders rests the responsibility of r<. -^resenting to the public the stand- ards and ideals of the medical profes- sion. In these three States there is a combined total population of over six and one-half million people who are looking to the 6,233 regularly licensed physicians in these three States, to pro- tect them from difeease and cure them when ill. These 6,233 doctors are fine men and fully able to carry this tre- mendous responsibility, but there is not a m.an among this number that could not be better able to carry his load if he frequently met and mingled with his fellows for a mutual and harmonious interchange of experience and ideas. Just as re-breathing of air leads surely to physical death so re-breathing of ideas leads as surely to mental death. For the sake of these millions who have pinned their trust on the medical pro- fession of these three States, every doc- tor should feel it his moral duty to man- kind to affiliate himself actively with his medical societies and attend the meetings. For every client lost because of being away for the purpose of gen- uinely striving to better fit oneself to fulfill life's duties and obligations to the community in which we live, there will be many others to fill that vacant place. And ten shots to one the new ones will be better pay and in every way much more desirable to work for. Come to Norfolk for the purpose of giving and getting. Come with the proper spirit and in the proper attitude for making this meeting a real and gen- uine event in the history of medicine. Ask your neighbor to come along; You will be repaid a thousand fold and the people at home will appreciate you more as the years go by. January, 1922. EDITORIAL 41 If you are not a member you ought manency; and from 3 per cent no re- to be — but whether a member or not, port has been received, come any way. I ong Gloves in Obstetrics — Whatever Among the hotels at Norfolk we will attitude one may have to the routine mention the Monticello, the Southland, the Fairfax, the Lorraine and the At- lantic. Gynecology and Obstetrics Rr)bert K. Seil)els. M. D.. Dept. fZditor GYNECOLOGY AND OBSTETRICS— Hemorrhage from the Nonpregnant Uterus in the Absence of Neoplasm. — Under this title, Scott, Am. J. Obs. & Gyn., Vol. 11, No. 5, discusses the pa- thology and the treatment of these cases. Clinically they are usually term- ed "Myopathic Hemorrhage" or "Fib- rosis Uteri." The pathological picture is not characteristic and the microscope seldom gives any clue to the underlying cause — the thickened endometrium of- ten found is not unlike that seen in the ordinai'y pre-menstrual molimina. The curet has been abused in the performance of version, according to the teaching of Potter, he has added two most valuable contributions to the practice of obstetrics. The first, a safe method of performing version, and the other is the advocacy of elbow-length gloves. For intra-uterine manipula- tions, the 21-inch glove has distinct ad- vantages over any of its substitutes, not least of which is its sterility. This length glove has been put on the mar- ket by one firm at the cost of $2.75 the pair — expensive as compared with short gloves, but well worth the difference in the added safety to the patient. Urology A. J. Crowell, M. D., Dept. Editor Urine — Burtis M. Hance, J. M. New Jersey, 18:322, October, Cloudy Soc, 1921. Cloudy urine indicates the presence of treatment of these cases, as it is often phosphates, urates, bacteria, pus, blood, still the first suggestion made in the at- mucus, hemoglobin or chvle. Phosphates tack. As Sampson pointed out in the and urates are unimportant, but urine discussion of the paper, the uterus does cloudv with bacteria, usually colon ba- not bleed when the musculature func- cilli, should be watched for six months tions, and the more or less complete re- or until a negative culture is obtained, moval of the endometrium has small, if Pus in the urine is caused by phimosis any, effect on uterine muscular tone. of the prepuce, by urethritis, anterior The condition is undoubtedly very or complete, by prostatitis and seminal frequently an endocrine disturbance, for vesiculitis, by cystitis, ureteritis and it is so often seen either at puberty or pyelitis, by perinephritic abscess, and the menopause— when the endocrine by tuberculosis of the kidney. In a case balance is at fault. Also the happy ef- of balanoposthitis caused by gonorrhea, feet of radiation leads to this view as the part was washed with soap and wa- ivdiation is beneficial through its action ter and soaked in a 2 per cent protargol on the ovaries. solution for ten minutes, with a re- The hemorrhage was formerly stop- suiting cure. The treatment for ureth- ped by surgery — subtotal hysterectomy ritis is known. Prostatitis and seminal being the operation. Radium or the X- vesiculitis are diagnosed by examina- ray are equally efficacious and in those tion of the expressed secretion, and the where the age indicates the conserva- treatment is massage. The prognosis is tion of menstrual function, three to four favorable. hundred milligram hours exposure is Cystitis, like cloudy urine, has many frequently followed by temporary amen- origins : gonorrhoea, pyelitis, ureteritis, orrhoea and after nine to ten months pyelonephritis, renal tuberculosis, tu- by the re-establishment of normal men- mors, stones, obstructions or duverticuli, struation. Jones, S. G. O., XXXIII, No. demanding cystoscopic examination for 12, reports the result of radiation in the discovery and removal of the cause. 129 cases, saying that 81 per cent have In the presence of blood in the urine, been relieved over two years; 16 per one must find the source, which may cent have been relieved but insufficient be (1) acute general infection; (2) in- time has elapsed to be sure of the per- farcts of the kidney; (3) cyanosis of 42 SOUTHERN MEDICINE AND SURGERY January, 1922. the kidney; (4) protozoa; (5) drugs; searching and must be established be- (6) nepritides — of interest to the in- fore treatment is begun. ternist; (7) trauma, particularly in- strumental; (8) tumors, such as papil- Recognition of the Bacillus of Koch in lomas, which may become malignant; the Urine — M. Maestre Ibanes, Siglo (9) verumontanitis and cystitis colli, Med., 68:861. Madrid, Sept. 10, 1921. showing blood as a terminal hematuria, Renal tuberculosis is now recognized and granulations in the posterior ure- much more frequently than formerly be- thra, treated by 25 per cent silver ni- fore the discovery of the tubercle ba- trate, administered through the endo- cilli in the urine. Cystoscopic methods scope; (10) calculi, with some pain, fre- and the catheterizing of each kidney quency of urination, recognizable by separately give data as to which organ means of the cystoscope, and curable by is affected. In order to distinguish a surgery; (11) ulcers, diagnosed by tuberculous pyuria from other types, means of the cystoscope; (12) tubercu- the following points are of diagnostic losis, identified by the finding of the aid. Tuberculous urine gives a mark- bacillus of tuberculosis or by inocula- edly acid reaction ; it contains a larga tion of guinea pigs, with intermittent quantity of pus, the globules of which cloudy urine, burning, frequency, pol- are deformed and irregular in outline, yuria, urgency and nycturia in patients with protoplasmic degeneration; the under 35 years of age. This should be nuclei stain poorly. In other pyurias the treated by removing the involved kid- reaction is strongly alkaline; there are ney or, when both are involved, by re- quantities of bacteria, and the leuokcy- moving the one most extensively dis- tes are well formed and stain well by eased. Additional causes are: (13) the usual methods. It is generally sup- cystitis; (14) benign prostatic hyper- posed that the urinary sediment usual- trophy, which should be operated on ly gives negative results, and that the while in the second stage; (15) pros- guinea pig inoculation test is the only tatic carcinoma, with constant oozing diagnostic method available. The au- and sometimes profuse bleeding late in thor, however, found tubercle bacilli in the disease. As diagnosis is usually too 82 per cent of the sediments examined, late for surgery, radium is indicated, and only used the guinea pig test as a The condition may also be due to: (16) last resort in the remaining cases, stricture of the ureter with vesical The following technic is used: The symptoms and referred pains in the urine stands for twelve hours and then hips and thighs, diagnosed by the aid 100 c.c. of urine with sediment are of the wax bulb catheter and having a used ; the latter is centrifuged and de- fa vorable prognosis; (17) stricture of canted, and to the sediment obtained is the urethra, which is a healed ulcer, added a new supply of urine, and the having a history of burning and diffi- process repeated until the 100 c.c. are cult urination, and being diagnosed by all centrifuged. When the urine is very means of the Otis bulb and treated by purulent, or has a high albumin, glucose gradual dilatation or, if this is impossi- or urate content, it is necessary to di- ble, by external urethrotomy; (18) lute the content of the two tubes with chancre of the urethra, with a serous, 10 c.c. of water alkalized with soda, boil bloody discharge, with little pain and for ten minutes, cool, centrifuge and no obstruction, recognizable with the decant. Two drops of this are placed dark field illuminator; (19) foreign on slides, warmed, and more sediment bodies, usually removable by means of added. The preparation is fixed with the operating cystoscope; (20) essen- alcohol-ether and stained by the Ziehl- tial or diopathic hematuria; and (21) xt i ^i- j -nu- ^.u i i- • hemoglobinuria or frost hematuria, ^eelsen method. This method elimi- caused by a dissolution between the red- "ates those substances which obstruct cell stroma and its coloring matter, due the microscopic observation. If the albu- to cold and dampness. Cloudy urine is min content is light, dilution with al- also produced by mucus due to stone, Valine water is not necessary. This infection, tuberculosis, etc., hemoglobi- ^.v j • xu 4- ^ j.-^ r nuria and chyle, which is caused by "^^'^^^^ gives the greatest quantity of Filaria sanguinis nominis. With any sediment m the smallest volume. Care unusual bladder or urinary conditions must be used not to allow the urine to the proper diagnosis requires diligent decompose. January, 1922. EDITORIAL Mutaflor in Bacillus Coli Infections of the Urinary Tract — Rorig, Munch, med. Wchnschr., 68-980, August 5, 1921. Whereas, autogenous vaccines rarely rid the urinary organs entirely of the colon bacillus, mutaflor does remove the infection rapidly and completely if un- hindered by unfavorable anatomic rela- tionships, such as extensive cavaties and ulcerations in the renal pelvis, stones, scars and atrophy, strictures, etc., in the intestines. The effect of mutaflor is weakened by dilatations of the renal pelvis, strictures of the ureter and urethra, prostatic hypertrophy and chronic inflammation with residual urine and prostatic and vesical calculi, in which conditions the necessary oper- ations should be performed before mutaflor is administered ; under such conditions it gives excellent results when all other remedies fail. The dosage of mutaflor is gradually increased during the first two days up to three or four capsules daily on a fast- ing stomach, in the morning, or two capsules before the morning and even- ing meals for from four to six weeks. No unfavorable results were seen ; seven cases are reported, all of which showed amelioration and cure of the colon ba- cillus infection. Mutaflor is indicated in acute and chronic catarrhs of the mucosa of the urinary tract, in which it removes the bacillus and cures the catarrh ; in these catarrhs and moder- ate anatomic changes, additional local treatment gives excellent results; in gross anatomic changes, such as mark- ed prolapse of the renal pelvis, conpli- cating stones and tumors, and in pros- tatic hypertrophy with considerable residual urine, improvement results, but cures can come only after surgical in- tervention. A Ca^e of Albumin Calculi — Ernst Chrisfoph Meyer and Fritz Herzog, Med. Klin., 17:1062, Berlin, Sept. 1, 1921. A 15-year-old girl passed forty dirty- white, soft stones the size of a bean and lamellar in structure with her urine. The lamellae showed under the micro- scope that they were composed of bac- teria. They were for the most part in- soluble in potassium hydroxid, but were soluble in nitric acid, and calcium and potassium could be demonstrated in the solution, but no cystin, ammonia or magnesium. On nephrotomy a hard stone the size of a cherry was found, as well as many yellowish-white masses and structures similar to the calculi that had been passed. Recovery. Incrusta- tion of the concretions takes place by the crystallization of salts from the oversaturted solution of urine after de- struction of the colloid covering. Col- loids are deposited on the surface of foreign bodies such as shreds of mucus, blood clots, clumps of bacteria, or clots of fibrin. Then salts are deposited on them, followed by further layers of col- loid, etc. If there is no incrustation with salts, soft concretions are formed. This happens when the film of colloid is impenetrable by the salts. In the above case clumps of bacteria doubtless form- ed the nucleus of the stone and colloids were deposited around this. Mental and Nervous James K. Hall. M. n.. Dept. Editor Many people in the Stite of North Carolina may not know that the first thought of the late Governor Bickett upon entrance into public life was about the insane. Some years ago while the writer was a member of the Medical Staff of the State Hospital at Morgan- ton Mr. Bickett was elected to the Gen- eral Assembly from Franklin County. Immediately after the election he came to Morganton to ascertain of Dr. Mur- phy the needs of the hosoitals caring for the insane. As the result of that visit the young law-maker (perhaps this was his first office) the General Assembly made it possible for the State to issue in annual installments bonds to the amount of half a million dollars, and all of this money was spent in pro- viding for the needs of the insane. At Morganton, for instance, a small portion of the expenditure was for land on which cottages were erected for some of the hospital's employes, and to this day that little village is known as Bickett town. Some day the State should name for the late Governor a great building on the grounds of one of the State Hospitals. Governor Bickett possessed abundant intellectual equipment. He was unique in his thinking, in his speaking, and in his writing. Many of his phrases will live right on, along with Vance's. But SOUTHERN MEDICINE AND SURGERY January, 1922. he had qualities more commendable even than good sense. He had a good heart as well as a sound head. He thought clearly and justly and tenderly, too, about the great common people of the State — those whose position in life de- prived them of acquaintanceship with those in authority, and the writer hap- pens to know that the late Governor got most pleasure from office-holding in making of himself a servant indeed to these great plain folks. At first he fought for their insane, then for more adequate school facilities for them, and for a larger life in general, and if death had not taken him away too soon we now know that his life would have been rounded out as a great teacher of the great mountain people. His like had not been seen in the State since Vance. He had an almost uncanny but sympa- thetic understanding of his hopes and the inarticulate longings of the mass of the people, and they will miss their friend and their wise counsellor. In the Journal of the American Medi- cal Association of November 5, 1921, is published the paper entitled "Alcohol- ism in Relation to Mental Depression," which was read at the Boston meeting of the American Medical Association by Dr. Pierre Janet, of Paris. Those who have read Janet's "Major Symptoms of Hysteria" will remember how lucidly and delightfully he writes. Careful reading of the article in the Journal may help some prohibitionist to under- stand the morbid psychology underlying violations of the various anti-drinking enactments. Janet gives expression to the belief that alcoholism is the mani- festation of underlying mental abnor- mality. The mental condition in those individuals he generally finds to be that of depression, and it is for the purpose of lifting himself out of the depression that the man resorts to the use of whis- key. By experiment or by accident he has found out that alcohol makes him feel better, and for that reason he drinks. Such an individual, without stimulation, feels inadequate, afraid, blue, dejected, unhappy, but alcohol gives him courage and a feeling of be- ing fit, that he associates with normal- ity. This feeling of inefficiency may be persistent and tenacious, or it may exhibit itself only when some problem arises. In the first instance, there would probably be persistent drinking, but if the bad feeling comes only when action and courage are demanded, then the drinking would probably be of the periodic type. In Janet s opinion the alcoholic is not simply a drinking, drunken man, but he is the psychopathic individual who takes whiskey to make himself feel normal. Alcohol takes the normal man away from his mental normality into abnormality ; it lifts the dipsomaniac at first out of his depression into a more normal state. If the drinking be con- tinued to excess the physician is event- ually called upon to deal with a psyco- path who has become also an alcoholic wreck. In discussing the causes and the na- ture of the underlying morbid mental- ity which manifests itself in excessive drinking, Janet finds often bad mental heredity, occasionally poor physical health, not infrequently inadequate and improper nourishment and poor living conditions. He points out also a feature of our modern philosophical and politi- cal ideas which undoubtedly are often responsible for individual tragedies. We have become so accustomed to the preachment that all men are equal that we fail to be impressed by the fallacy and the folly of the idea, but we know well that one man can do with ease what another cannot even intelligently attempt, and Janet feels that individual effort to live in a plane for which one is not intellectually or emotionally equipped is certain to result in tragedy. The individual reaction to such disap- pointment may exhibit itself in alcohol- ism. Janet believes that some of the thought that is devoted to alcohol and to alcoholism should be given to the al- coholic himself, and that every effort should be made by the medical man to enable the alcoholic to understand him- self and his alcoholic reactions. The next annual meeting of the Tri- State Medical Association will be held February 22-23, 1922, at Norfolk, Va., with headquarters at the Monticello Hotel. January. 1922. EDITORIAL 45 Eye, Ear, Nose and Throat J. p. Matheson, M. D., Dept. Editor when inoculated and colonized in the human. The avirlence of the bacilli was confirmed also by the guinea-pig test. Fifty school children with positive cultures were selected and studied in . . detail. These fifty children who had Diphtheria Carriers positive cultures from first examination, A review of the work given in Johns only 28 showed positive cultures at the Hopkins Hospital Bulletin of November, second examination two weeks later. 1920, and of December, 1921, by Drs. The third examination showed only fif- Guthrie, Gelian, Moss and Marshall, is teen positive ones, and on until the sev- of great interest at this time, because enth examination revealed only six. The in the winter months diphtheria is most authors think that this progressive de- prevalent. cline in the number of positive cultures The 1,217 school children examined, indicates that the bacilli had actually 44 gave positive cultures of B. diphthe- disappeared from the throats of some ria, 3.61 per cent— 1,290 persons at of the children, but they do think, how- large gave 3.48 per cent positive cul- ever, that more than six of these still tures. In .-^peaking of this report, at- had positive cultures, tention is called to certain points in re- performed to ascertain gard to healthy diphtheria carriers, To ^^^^^^^^^ ^^^ ^^^jjU ^^^^ ^,.^^^^^^ ^^ ^" non-virulent. Six children showed vir- "1. Such carriers are relatively abun- yi^nt organisms out of fortv-seven car- dant in the community, as may be read- yi^y^ for whom the tests were complet- ily demonstrated by taking throat cul- ^^ (12 per cent plus). Some of the tures from a large series of individuals, conclusions drawn bv these investiga- particularly during the winter months, ^ors from the work they did were that The number of carriers revealed by a the diphtheria bacilli present in the ma- single examination may be approximate- joritv of healthy carriers are avirulent, Iv doubled bv a second examination of and that these cannot produce diphthe- the same series of nersons, and third, ria. Thev also believe that these car- examination still further increases the riers of avirulent diphtheria bacilli do number tound. not constitute a menace to the com- 2. The great majority (80 to 90 per munitv, and that their liberalities cent) of these healthy carriers harbor should not be interfered with, but the diphtheria bacilli which are non-viru- virulence of the organism of all healthy lent. These non-virulent diphtheria carriers should be ascertained, and if bacilli are to be distinguished from the found to be non-virulent, then the in- virulent ones, only by their inability to dividual should not be isolated, produce toxin. So far as we know, this ^^,, ., ., ^1 , . differentiation may be accomplished . ^\hile these authors have not seen a only by the inocculation of susceptible single case of diphtheria develop among animals ^^y °^ *^^ associates of the virulent „ ." ,, .LI 1 ,^1- • ^ diphtheria bacilli carriers, they are of 3^ Among all the healthy carriers of ^j^^ ^^^^^^ that these carriers are a diphtheria bacilli, virulent or non-viru- ^^^^^^ ^^ the individuals, and to the lent, studied by us, none developed clin- community at large, and therefore, ical diphtheria during the period of our ^^ould be isolated until they are clear observation although this was in many ^f ^he infection. They conclude their cases extended over several months and impressions in these words. "It is our even years. belief (1) that such carriers constitute 4. A painstaking investigation failed a potential menace to the health of the to reveal a single case of clinical diph- community but (2) that their oppor- theria developing among any of the as- tunity for dissemination of the disease sociates of the healthy carriers under among their associates is quite limited, our observation." owing to the relatively small number It was shown that non-virulent diph- of persons who are susceptible to in- theria bacilli may be inoculated from a fection and consequently (3) that the carrier to an individual and that this actual part which they play in the does not produce clinical diphtheria, nor spread of diphtheria is probably quite is the appearance of the throat changed small." SOUTHERN MEDICINE AND SURGERY January. 1!122. Orthopaedics Alonzo Myers, M. D., Dept. Editor Mobilization of the Elbow by Free Fas- cia Transplantation; With Report of Thirty-one Cases — W. Russell Mac- Ausland, Surg., Gyn. and Obstet., Sept., 1921. The causative factors of ankylosis are discussed. Author considers the elbow the joint most suited for arthroplasties. The history of arthroplasty, the devel- opment of the modern technique, and cases reported in the modern literature are gone into quite fully. The opera- tion is contraindicated until epiphyseal growth is complete. Infectious cases should not be operated upon until all signs of the active process have ceased. It is questionable if a tuberculous joint should be operated upon, certainly not until a number of years after it has been healed. Operative technique is carefully described and each step well illustrated. He uses a large, free flap of fascia lata to cover the raw surface of the end of the humerus. The head of the radius is not removed. After closing the wound, the arm is put up in a plaster cast, elbow less than a right angle. Stress is laid upon the after- care. Passive motions are begun in about ten days, gentle massage at three weeks, baking at six weeks. Occasion- ally, manipulation under anaesthetic is required, and in a few cases, exuberant bone was removed at a secondary oper- ation. The after-treatment was con- tinued for months. Twenty-eight cases are reported in full. There are a large number of good illustrations and roentgenograms of cases. A bibliography is appended. The article is a noteworthy contribution to the subject of arthroplasty. The re- sults obtained seem to justify the oper- ation of arthroplasty of the elbow, in spite of the fact that some authorities are still in favor of excision. Bone Atrouhy: An Experimental and Clinical Study of Changes in Bone Which Result from Non-use — Na- thaniel Allison and Barnev Brooks, Surg., Gyn. and Obstet., Sept., 1921. This article should not be abstracted. It is so well worth while that it should be read in its entirety by everyone in- terested in bone pathology. There are a number of good illustrations and sev- eral interesting tables. The purpose of the experimental and clinical study is to determine the effect of non-use of bones as it concerns: 1, X-ray photographs; 2, gross and microscopical anatomy; 3, chemical composition ; 4. breaking strength ; 5. growth ; 6. regeneration. Dogs were used. Three methods were used to prevent the use of the foreleg: a. Section of the brachial plexus — 13 ex- periments ; b. Excision of the upper end of the humerus — 7 experiments; c. Plaster of Paris fixation — 4 experi- ments. Discussion : Regardless of the meth- od used to cause non-use, the changes in the bone were the same. The degree of atrophy of the bone was directly pro- portional to the degree of non-use. There is no evidence warranting the as- sumption that any disease process plays any role in the production of bone atrophy other than its effect on use. Bone atrophy is not the result of di- minished circulation of blood. Bone atrophy is an active process, and the circulation of the blood is nec- essary to its progress. The process of bone atrophy is not a change in the characteristics of bone as a substance. The process of bone atrophy is a change in the amount of bone present. This affects the size, shape, thickness, length, weight, and texture of the whole bone, and accounts for its changes in gross anatomy. X-ray photographs, breaking strength, and chemical com- position. The chemical composition, breaking strength, and regeneration of bone remains unchanged. The above conclusions are logically drawn from all the experiments and agree with clinical experience. Posture in Relation to Medical and Sur- gical Problems — John Allan Talbott, Virginia Medical Monthly, Sept., 1921. The author calls attention to the vast percentage of physically unfit among the young men of draft age in this coun- try, citing the fact that in the State of Massachusetts, 46 per cent of the draft- ed men were refused on account of phy- sical disability. Many of these, how- ever, had disabilities which were reme- diable, such as backache, weak feet, in- fected teeth, et cetera. The experience of the recent war demonstrated the fact State Medicine L. H. M (■I5rayer. .M. I)., Dept. Editor January, 1922. EDITORIAL 47 that many became physically disabled occupation is also true in part of mem- while in the service, and by training, bers of society who do not engage in particularly under the observation of gainful labor at all, or engaged in it to orthopaedic surgeons, were benefited but a limited extent; as children, and pnd later returned to active service, women not engaged in work that is di- while others were placed at work, which rectly gainful. rhey were able to do, behind the lines. He cites from Lloyd Brown, that of the The maintenance of a condition of 746 men at Harvard, 80 per cent show- health, for the individual and the com- ed postural defects. While the author munity, is a scientific problem involving does not go into the surgical and medi- many matters of conduct and of envir- cal problems relating to poor posture, onment. The essential agent — and es- he has mentioned an important subject pecially at this particular stage in the and brought to the attention of the pro- development of this science — in the fession again the importance of correct maintenance of the prime economic fac- posture, especially with those unfortu- tor of health is the physician ; whose nate individuals who suffer from such function is twofold. To apply a scien- conditions as visceroptosis, et cetera, tific knowledge and skill in extreme in- and whose problems are unsolved and dividual derangements or neighborhood little benefited by usual treatment. conditions; and to instruct the people of the community in matters of conduct and environment which they should learn to control. Medical science is moreover a science of rapid growth. Thousands of its prac- titioners are engaged to some extent in The Professional Equipment of the adding to the body of the science all Country Doctor the while. A select few, by comparison (Editorial from The Greensboro Daily )vith the whole body, but numbering News. Mav 2, 1916, W. A. Hildebrand, thousands m the aggregate devote then Fdi'or ) ' snecial native and acquired skill as m- Health is the prime economic factor, vestigators, not to the P^'evention or Ue-^Vh is static labor. More strictly, cure of disease directly ^.V the se ot health is that condition of the animal in the body of the science already c leated which the materials of food, water and ^"^ tested, but mainly to the addi^^^^^^^ rir are utilized most economicallv in the ^'^ accumulation ot such knovv edge, production of energv, which may be em- Developments in P^'.^ventive theiapeu- ploved in muscular or mental labor. tics have been especially marked of lae Failure to maintain this condition of ^ears, so that it might almost be aid pssimilative efficiencv-assimilation be- that within a decade a new Pjofes^io" ing the bodilv process of transmitting ^^s g^own up withm the od one of bread and meat into money, through la- ^^^tor of Medicine-the special piofes- bor (the laborer eats breakfast and toils until noon ; eats dinner and toils until evening, and is paid off in silver) — may It is apparent that the efficiency of a result in waste in many ways. Time is people must depend upon the people's lost; that is to say, passes without its physicians; that comparative efficiency equivalent in productive labor. Food, — the efficiency of a neighborhood, as which costs money, does not produce compared with other neighborhoods, or any return, or the return is less than as compared with possible standards — is the cost of the food. The laborer, to be maintained through the agency of through ill health, may be cut off, long a scientist who must enter upon his before the period to which he should work well equipped, but moreover must have worked ; depriving his family, and devote a part of his time to additional his community, of years of productive equipment, in order to keep step with labor. Or he may "^linger in unhealth, the advance of his science. When we entailing not only certain expenses of say the efficiency of a people we mean food and clothing and housing, but med- their comparative freedom from the ical care, skilled nursing, especial diet, positive losses of illness and premature medicine. What is true of the man who death from preventable disease ; their would in health be engaged in gainful comparative ability to work with their sion of Doctor of Health. 48 SOUTHERN MEDICINE AND SURGERY January, 1922. hands, to think, to learn, to keep up decisions under these circumstances, he with the advancing standards of pro- must be under the most perfect self-con- ductiveness in whatever field they work; trol, with every one of his senses in per- their comparative ability to live and to feet condition and exquisitely respon- enjoy. sive to the slightest indication. This is The population of our State being not possible if he is living under home about 80 per cent rural, most of our conditions of congestion and insufficient comparison must have to do with the light and comfort, if he is harrassed by ability of the people to farm. Now, debts or constantly worried as to mak- farming, it so happens, is also at this ing both ends meet ; if he is hounded by time a rapidly advancing business. It the spectre of future want for his fam- is advancing as a science, because scien- ily or himself; or if he is mercilessly tists are pushing it, following scientific driven in the effort to see the largest principles of experiment and research, possible number of patients in each 24 These investigators are also teachers ; it hours. is not necessary for the farmer to be a "No one can be more solicitous for the scientist, but it is necessary for him to economic well-being of the medical pro- follow the instruction of these investi- fession than the social worker who is gators. They are paid with his money ; face to face daily with the fact that they are working for his assistance, competent diagnoses and sound medical The health factor is more essential now treatment are elementary necessities in than it has ever before been, in the goo:l relief work, to say nothing of the business of farming, because farming is importance of preventive medicine in a business requiring mental growth, the reduction of dependency. For this constant increase of knowledge, and the reason the social worker and the lay unhealthy individual or community is public health worker are particularly not m growing condition. glad to use every possible opportunity What IS the condition of the average to increase the proportion of the sick physician with reference to his profes- who seek medical care. A large part of sion— a profession that is advancing so every public health movement consists that he must give to it time and study, of saying in many different ways, 'See if he would be m a position to give his your doctor early and follow his instruc- people the best service? The people of tions.' A successful public health cam- North Carolina being mainly rural, this paign would undoubtedly ultimately di- question becomes one of the average minish greatly the amount of sickness efficiency of the country doctor. to be cared for but unfortunately it is a , distant eventuality. Until now, and for rru J*J^} LTnderpay the Doctor gome years to come, the first and one of The State Chanties Aid Association the most prominent effects of every News of New York City, in its issue of public health campaign is to increase December, 1921, had the following to the volume of work actually done by say under the above title: the medical profession." No community can afford to have its Roentgenology Robt. H. Lafferty, M. D., Dept. Editor medical profession unpaid," said Homer Folks, Secretary of the State Charities Aid Association, speaking before the Harlem Medical Society recently on "Economic, Preventive and Social Defi- ciencies of Medical Practice." The meeting of the Radiological So- "A poorly paid physician is a men- ciety of North America in Chicago, De- ace," said Mr. Folks. "Our physicians cember 6th to 10th, was without doubt ask us a few questions, look into our the greatest meeting of radiologists throats, listen to our hearts and lungs, ever held ; greatest in attendance, with tap us a few times on the chest, and per- a registration of 750 ; greatest in pro- haps make a few other tests, and on gram, with about 60 high grade papers. this information, gained in a few min- The foreign guests were Drs. Guillemir utes, they make decisions and give in- not of Paris and Bachem of Frankfort, structions, the soundness of which may X-ray programs of today arc very mean life or death to the patient. More different from those of a few years ago. than any other man, the physician needs Then the vast majority of papers were to be always at his best. To make safe on diagnostic phases and it was hard to January, 1922. EDITORIAL 49 jret anything on treatment and practi- uniformly good attention and with such cally nothing on Physics. Today the careful adherence to the schedule as the programs are replete with radiotherapy President, Dr. Alden Williams of Grand and physics and there are few diagnos- Rapids, did this. For the reading of tic papers. This program was no ex- about 60 papers the sessions covered ception. There were about a dozen very about 40 hours. high grade papers on diagnosis. Car- At the convocation honorary degrees men of the Mayo Clinic discussed of Fellow in Radiological Society of "Some Errors in Diagnosis of Duodenal North America were presented. Dr. Ulcer." Cole classified duodenal ulcers Wm. Duane of Harvard and Dr. G. E. into six classes, which produced quite a Phahler of Philadelphia, bit of di.scussion. Which recalls a re- The four gold medals of the Society mark of Dunham in his address at the were awarded as follows: Dr. Kennon Hot Springs meeting when he offered Dunham of Cincinnati, in recognition of a classification of pulmonary tuberculo- his work on Radiography of the Chest; sis. He paraphrases the quotation. "Oh. Dr. Lewis G. Cole of New York for that mine enemy would write a book," work on Gastric and Duodenal Diagno- into "Oh, that mine enemy would make sis; Dr. A. W. Crane of Kalamazoo for a classification," saying that he realized work in correlation of X-ray and clini- the great danger in proposing a classi- cal medicine; Dr. H. E. Potter of Chi- fication. The other diagnostic papers cago for work in perfecting the Potter on chest, gall-bladder, anomalies of the gridor Buckey Diaphragm, gastrointestinal tract and Van Zwalu- The next president is Dr. Albert Soi- wenburg on the "Pneumoperiteum of land of Los Angeles and the president- the Female Pelvis," were all of especial elect is Dr. Russell D. Carman of Mayo merit. Clinic. The mid-year meeting will be Dr. Peterson's paper on "Organ Stim- held just prior to the meeting of the ulation bv Roentgen Ray," and Dr. A. M. A. at St. Louis and the next an- Wood's paper on "Biological Determina- nual meeting is to be in Detroit next tion of X-Ray Dosage" formed a trio December, of wonderful napers reporting original work. Hospital and Sanatorium )hn Q. Myers, ^.l. D.. Dept. Editor Dr. Warthin's report of his work on "Differential Microscopical Diagnosis of Effects of Irradiation" showed indispu- table and verv characteristic results on mi xt i.i ^ i- tt -i. i a the thvroid and adenoid tissues. Mo.st ,,.The North Carolina Hospital Associa- other tissues, while thev showed strik- t^ion will meet at the Sheraton Hotel, ing changes, the change was not abso- High Point, N^ C. Tuesday mornmg lufelv characteristic of irradation. Ja""^^'^ 31 1922, at 10 A. M., and will While all the papers on massive ther- continue three sessions curing the day apy contained some physics the out- ^^'^^h a banquet by a local committee on standing phvsical papers were by Drs. arrangements at night. Duane of Harvard, GuilleminoT of Paris r.^^'^^^J^T'^l^^r^ °" Arrangements: and Bachem of Frankfort. Drs. H B Hiatt Chairman ; F^G. Wood- The papers on treatment were very ^^u^; W- J- McAnnally, L T. Mann, and comprehensive, covering the treatment ^* ^' ^^itzei. of malignancv bv combined X-rav and There will be a splendid program and radium, and "the' treatment of fibroids, Papers presented by leading hospital tonsils, toxic goiter, carbuncles and men and women of the State. All who other benign conditions amenable to X- are interested in the upbuilding and rav. Dr. Pfahler in his usual thorough maintenance of the hospitals of North manner discussed "The Treatment of Carolina should attend this meeting. Epithelioma of the Lip by Electric which will be of great benefit to every- Coagulation and Radiation." one. Taken all in all, the program was well "In Unity There is Strength." balanced, covering all the important "United We Stand." In co-operation phases of radiation and it has never there is growth and development. It is before been the privilege of the writer a duty we owe ourselves and our coun- to see such an elaborate program car- try to take advantage of every oppor- ried through so long a period, with such tunity to improve ourselves and there- 50 SOUTHERN MEDICINE AND SURGERY January, 1922. by be better able to improve our meth- A meeting of the Fifth District Med- ods and management of hospital admin- ical Association was held in Winnsboro istration and caring for the unfortunate October 20. The following are officers and sick. of the Association : Dr. W. R. Wallace, President; Dr. G. W. Poovey and Dr. W. M. Love, Vice-Presidents; Dr. G. A. News Items Hennies, Secretary-Treasurer. The Davidson County Medical So- ciety, at its annual business meeting, elected the following officers for 1922: Dr. J. R. Terry, President; Dr. J. E. Hobgood, Vice-President; Dr. R. V. Yokley, Secretary and Treasurer. Dr. D. J. Hill was again chosen as delegate to the State Medical Society, with Dr. C. A. Julian, alternate. There was a full attendance and a most satisfactory meeting. Williamsburg County Medical Society has elected the following officers: Dr. W. G. Gamble, President; Dr. E. T. Kelly, Vice-President; Dr. B. M. Mont- gomery, Secretary-Treasurer. At the regular meeting of the Hen- derson, Polk County, Medical Society, the following officers were elected : Dr. E. P. Mallett, President ; Dr. B. F. Cliff, Vice-President; Dr. R. C. Sample, Sec- retary and Treasurer; Dr. Guy E. Dix- on was elected to the board of censors, also as delegate to the State Society meeting, with Dr. E. P. Mallett as al- ternate. All of these reside at Hender- sonville. The Mecklenburg County (Charlotte, N. C.) Medical Society, at its annual meeting in December, elected the fol- lowing officers for 1922: President — L. W. Hovis. Vice-President— H. W. McKay. Secretary-Treasurer — J. L. Ranson, Board of Censors — W. W. Pharr, A. G, Brenizer, R. W. Petrie. Delegates to N. C. Society— I. W. Fai- son, R. F. Lineback, J. Q. Myers, J. R. Alexander. Alternates, J. M. Northing- ton, J. R. Irwin, John Donnelly, M. L. Townsend. Program Committee — J. P. Kennedy, R. H. Lafferty, J. R. Shull. New members of the Society are H. C. Shirley, F. D. Worthington, C. L. Nance. The Manchester Medical Society, Richmond, Va., was entertained at the home of Dr. T. D. Jones on the evening of January 3. A number of physicians from Richmond were present and the occasion was most enjoyable. The Southampton County Medical Society has elected the following offi- cers for 1922: Dr. B. A. Pope, Presi- dent; Drs. E. F. Reese and H. H. Fos- ter, Vice-Presidents; Dr. R. L. Raiford, Secretary-Treasurer. At the regular meeting of the Rich- mond Academy of Medicine and Sur- gery on the evening of December 31, 1921, Dr. A. C. Christie, of Washington, by invitation, read a paper dealing with ulcer of the stomach and the duodenum from the point of view of the X-ray examiner. i . At the meeting officers were elected for the year 1922: President, Dr. Jas. K. Hall ; First Vice-President, Dr. R. D. Garcin ; second Vice-President, Dr. W. H. Craig; Third Vice-President, Dr. J. R. Blair. Dr. M. W. Peyser was re-elected sec- retary. He has been re-elected to this position for the past twenty-eight years. The Board of Directors of the Dan- ville Anti-Tuberculosis League has let the contract for the construction of a modern sanatorium just outside of Danville. At a recent meeting of the Richmond Chapter, Military Order of the World War, Col. J. Fulmer Bright was elected Commander; Maj. G. A. Ezekiel, Adju- tant, and Col. Garnett Nelson, Histo- rian. These are all practicing physi- cians in Richmond. Lenoir Hospital Campaign now under way for raising $30,000 for the erec- tion of new hospital at Lenoir, N. C. It is contemplated that the new com- pany will take over the property of the old Foothills Sanatorium Company and January, 1922. EDITORIAL 51 thoroughly remodel and modernize the and is very ill in a Charlotte Hospital. buildings. The equipment will be com- plete in every detail Dr. L. A. Crowell, Dr. R. D. McMillan has moved from ot Lmcolnton, N. C, will operate the Red Springs, N. C, to Hinton W Va new hospital under lease, in connection with offices in the Brotherhood Build- with his own hospital at Lincolnton. ing. All of North Carolina and also the TVT u w , . „,., . . ^r ^ Tri-State Association regret very much New Hcspital m Wilmington, N. C. that Doctor McMillan is leaving this Drs. Bulluck and Davis, Wilmington, territory and yet we all wish for him N C, now have under construction a in his new location every possible sue- thoroughly modern and up-to-date cess. building to be used as a private hos- pital. The construction is brick con- Dr. Wallace E. Coltrane, Dunn N C Crete fireproof, three floors, and will ac- recently was operated on in Raleigh for commodate 30 beds, located in the heart appendicitis, and at this date is recov- of the business section. ering nicely. A campaign for .$2.5,000 has been con- The Raleigh Nurses Association held ducted in Durham with which to com- its annual meeting January 11 and plete the sum necessary for the con- elected new officers struction of a $150,000 negro hospital. One citizen gave a sum of $75,000 on Dr. and Mrs. S. R. Horton Raleigh condition that it be met by city and N. C, spent the Christmas holidays at county and the colored people. Norfolk and Smithfield. The will of the late George W. Watts, Dr. Newton Robinson, Elizabethtown, \Vest Durham, provides $200,000 for N. C, died December 19, 1921. He had the Uatts Hospital. practiced medicine in Bladen county for r» i:. ^ ». ^. "^, "^°^^ ^^^" ^^ years, a real gentleman Dr E. C. McClees, Elm City, N. C, of polished and reassuring presence, and Miss .Jane Bullock, Montgomery, who ingratiated himself in the hearts Ala., were united in marriage at the of all who knew him. home of the bride in that city on De- cember 29, 1921. Dr. DeWitt R .Austin, graduate of r. T^ ... :~, ^^^ University of Pennsylvania, has lo- Dr. Prank Johns, of the Surgical Staflf cated in Charlotte, N. C, associated ot the Johnston-Willis Sanatorium with Dr. Fred D. Austin, practicing in Richmond, gave a delightful dinner Urologv. to tne members of the hospital staff at * his home on the evening of January 4. Dr. H. R. Fairfax has been appointed nr c w x> jj . „. , , , Health Officer of Bristol. Dr. S. W. Budd, of Richmond, has just completed the installation in con- r.^ j^^^. r^^i^i^ ti, t> i ncction with his laboratory of a radium , ^F^T. ^^^'^^on Thomas, Roanoke, emanation plant. He is^^pared t^ ^^S ^"if mT"''" Winthrop Griffiss, treat all conditions in which radium ^^^esville, Md., were married Nov. 14. therapy is indicated and on each Friday ^ „,.„. he will hold a free clinic. ^^- William W. Dickie, Richmond, aged 87, died Nov. 4 at the home of his Dr. V. M. Hicks, former House Sur- daughter. geon of the New York Eye and Ear In- firmary, has recently joined the old firm Dr. Daniel Castillo Graham, aged 32, of Drs. Lewis, Battle & Wright, his died Oct. 22 at St. Luke's Hospital, practice limited to diseases of the eye, Bluefield. and the firm is now known as Drs. Lewis, Battle, Wright & Hicks, Raleigh, Dr. Wm. Simonton Pack, Greenville ^^- C- S. C. ; Medical College of the State of -^ ,,., South Carolina, Charleston. 1889; mem- Dr. Miles J. Walker, York, S. C, is ber of the South Carolina Medical As- suffering with an acute exacerbation of sociation,. died December 12, following an old chronic osteomyelitis of femur a long illness, aged 60. 52 SOUTHERN MEDICINE AND SURGERY January, 1922. Dr. Leland Carson Mcintosh, Hender- son, and Miss Bessie Lee High, Campo- bello, S. C, were married Nov. 3. Dr. H. P. Underhill, Wendell, aged 44, died at Marv Elizabeth Hospital, Nov. 18. Dr. Frank G. Wilson, Gastonia, aged 48, died November 13 from cerebral hemorrhage. These groups are : Alimentary Tract, Urogenital organs. Ductless Glands, Heart, Blood, Skin and Syphilis, Head, Trunk and Extremities, Nerves, Tech- nic, and General. All of this is well in- dexed so that any one paper is easily found. The collection covers most fully present day medicine and surgery. Dr. Allston David Horah, Salisbury, aged 57, died Oct. 19 in the State Hos- pital for the Insane, Morganton. Dr. John F. Sanderford, Creedmore, aged 57, died Nov. 12 in the Watts Hos- pital, West Durham, from Uremia. A Public Health Institute will be held at Columbia, S. C, some time in Janu- ary. THE SURGICAL CLINICS OF NORTH AMERICA. Vol. 1, No. 4, The Chi- cago Number; Vol, 1, No. 5, Mayo Clinic Number; Vol. 1, No. 6, New York and Index Number. Published Bi-monthly. W. B. Saunders Com- pany: Philadelphia and London. These clinics are proving almost in- dispensable to the surgeon who wants to do his full duty to his clientele and keep up with the latest and best in the field of surgery. The Thompson Memorial Building of the Roper Hospital has been completed. This will be known as the Riverside In- firmary. The old building will be re- modeled and used for a nurses home. Mrs. K. P. B. Bonner, wife of Dr. K. P. B. Bonner, Morehead City, died Jan- uary 6, 1922, age 35. Mrs. Bonner had been ill for several months. Sir Harold Stiles, Regius Professor, University of Edinburgh, has been vis- iting his fellow graduate. Dr. Tom A. Williams, in Washington. Sir Harold came to America to give the convoca- tion address before the American Col- lege of Surgeons, and has visited sev- eral of the chief surgical clinics also. Publications Received 1920 COLLECTED PAPERS OF THE MAYO CLINIC, Rochester, Minn. Edited by Mrs. M. H. Mellish. Oc- tavo of 1,391 pages; 446 illustrations. Philadelphia and London: W. B. Saunders Company. Cloth, $12.00 net. The arrangement of this work groups the papers on the various subjects in general groups and correlates them in a way which gives a full and clear presen- tation of the subjects. DISEASES OF THE DIGESTIVE OR- GANS with special reference to their diagnosis and treatment. By Charles D. Aaron, ScD., M.D., F.A.C.P., Pro- fessor of Gastroenterology and Diet- etics in the Detroit College of Medi- cine and Surgery ; Consulting Gastro- enterologist to Harper Hospital. Third edition, thoroughly revised. Illustrat- ed with 164 Engravings, 48 Roentgen- ograms and 13 Colored Plates. Lea & Febiger: Philadelphia and New York, 1921. Price, $10.00 net. The plan of the work, like the preced- ing two editions, follows the physio- logic path of the digestive tract, begin- ning with diseases of the mouth, and taking up in succession the pharynx, esophagus, stomach, liver, gall, bladder, bile ducts, pancreas, small intestine, vermiform appendix, cecum, colon, sig- moid flexure, rectum and anus. The au- thor has put before the practitioner, in an orderly and consecutive manner, the diagnosis and treatment of digestive diseases, and to make available all the resources at his command. The physi- ology of digestion has been considered from the viewpoint of the clinician rather than from that of tlie physiolo- gist. Much attention has been given to recent progress in the study of internal secretions, which has contributed much to the knowledge of the physiology of digestion. Chapters are devoted to the stomach tube, the duodenal tube an its employ- ment in the drainage of the gall blad- der and bile ducts, to the roentgenog- January, 1922. MISCELLANEOUS 53 raphy of the esophagus, stomach and in- testines, general dietetics and hydro- therapeutic measures. Several chapters are devoted to gastric disorders classed as neuroses. The entire subject of gastroenterol- ogy is covered in a thorough and com- prehensive manner and the book is well worth while for every practitioner of medicine. tions. The author starts in with a full description of the microscope, its care, its accessories and microscopic technic, and follows his subject on through in the same thorough manner, covering the entire field of Laboratory Diagnosis. Blood, Urine, Body Fluids, Feces, Ani- mal Parasites, Bacteriologic Methods, Sero Diagnosis, etc. DISEASES OF THE SKIN. By Rich- ard L. Sutton, M.D., Professor of Dis- eases of the Skin, University of Kan- sas School of Medicine; Dermatolo- gist to the Christian Church Hospital, former Chairman of the Dermatologi- cal Section American Medical Associa- tion. Fourth edition, revised and en- larged. 1,182 pages; 969 illustrations and 11 colored plates. C. V. Mosby Co., St. Louis. Price, $9.50. One is struck by the practical way in which the author handles this subject. Particular emphasis has been placed on pathology and treatment with advice to the less experienced practitioner which does not confuse. The commoner dis- orders, such as eczema and syphilis, are given the greater amount of space and yet the rarer dermatoses are fully cov- ered, and a number have been pictorially presented for the first time in any book. RINGWORM AND ITS SUCCESSFUL TREATMENT. By John P. Turner, M.D., Medical Inspector of Public Schools, Philadelphia, 65 pages with 8 Half Tone Engravings. F. A. Da- vis & Co., Philadelphia. Price, $1.00. Not a big volumn but full of truth. Dr. Turner's remarkable achievement in the complete cure of this obstinate con- dition is deserving of medical notice, and this volume gives the medical man just the information and help he has been seeking. THE EMERICAN YEAR BOOK OF ANESTHESIA AND ANALGESIA. 19 '8 Edition. F. H. McMechan, A.M., M.D., Editor. Surgery Publishing Company, 15 E. 26th St., New York City. The editor has presented this book in a manner and style that makes it ap- peal to all those progressive members of the allied professions and specialties, who in any manner come in contact with the science and practice of anes- thesia and analgesia. Besides covering the recent progress in these subjects this work provides the anesthetist, den- tist, research worker and surgeon with those special advances that have a di- rect bearing on his individual require- ments. Volume 2, like Volume 1, has been compiled of exhaustive articles by prominent authorities and as evidence of the position which the Year Book has achieved it may be stated that a copy of Volume 1, 1916, was placed by the National Anesthesia Research So- ciety in every institution where the sub- jects of Anesthesia and Analgesia are taught. ESSENTIALS OF LABORATORY DI- AGNOSIS. Designed for Students and Practitioners by Francis Ashley Faught, M.D. Seventh revised and enlarged edition. 523 pages; 78 text engravings and eleven full page plates. F. A. Davis & Co., Philadel- phia. Price, $4.50 net. This edition has been completely re- vised and in fact pi-actically re-written in an effort to embody many of the new and valuable methods, found practical since the preparation of the former edi- SUBMUCOUS RESECTION OF THE NASAL SEPTUM. By W. Meddaugh, Dunning, M.D., Consulting Otologist, Fordham Hospital, N. Y. C. ; Consult- ing Otologist, Manhattan State Hos- pital, N. Y. ; Consulting Laryngolo- gist, Ossining City Hospital, Ossin- ing, N. Y. ; Consulting Laryngologist, The Alexander Linn Hospital, Sussex, N. J. ; Assistant Surgeon, Manhattan Eye and Ear Hospital, New York; Surgeon, Bronx Eye and Ear Infirm- ary, New York. Over 100 pages of text, illustrated by 25 pages of draw- ings, printed upon heavy coated book paper and substantially bound in cloth. Price, $1.50 postpaid. Surgery Publishing Company, 15 East 26th Street, New York. 54 SOUTHERN MEDICINE AND SURGERY January, 1922 A most complete and comprehensive language of one of the makers of mod- book describing the very latest tech- ern medicine. The edition is limited to nique in Submucous Resection of the 500 copies, of which 400 will be offered Nasal Septum. for sale. Price, $3.00 postpaid. Medi- Dr. Dunning's extensive experience in cal Life Company, New York City. submucous work especially fits him to write an instructive book upon this sub- THE ROCKEFELLER FOUNDATION. ject. Annual Report. The Rockefeller Its contents thoroughly covers The Foundation, 61 Broadway, New York Nose, Breathing and Smelling, Common City. Septal Deviations, Surgical Procedure in Submucous Resection of the Nasal STATE LAWS AND REGULATIONS Septum, Special Surgical Procedure, PERTAINING TO PUBLIC Typical Case Histories and Their Sig- HEALTH. nificance. The Saddle-Back Nose, etc. The minutest technique of the opera- PROCEEDINGS OF THE FIFTEENTH tion and text is clearly visualized by ANNUAL SESSION OF THE ASSO- twentv-five especially prepared draw- CIATION OF LIFE INSURANCE ings. It is the only recent book upon PRESIDENTS. this subject. While text books upon nose and TRANSACTIONS OF THE AMERI- throat work devote some chapters to CAN PEDIATRIC SOCIETY. submucous resection of the nasal sep- tum, their authors cannot devote a suf- TREASURY — ANNUAL REPORTS ficient amount of space to comprehen- U. S. PUBLIC HEALTH SERVICE. sively describe and illustrate the com- plete technique of the operation and "SMILING PASS" — Being a Further after-treatment. Account of the Career of "Smiles," a Rose of the Cumberlands. By Eliot PRACTICAL MEDICINE SERIES, H. Robinson, Author of "Smiles," 192L Eight Volumes. Price, $12.00. "The Maid of Mirabelle," "Man Pro- The Year Book PubHshing Co., Chi- poses," "Go Get 'Em!" and "With cago, Ills. Old Glory in Berlin." The Page Com- The first four volumes of this series pany, 53 Beacon St., Boston, Publish- have been received and are: ers. General Medicine, Billings, Raulston, The thousands that have read and 630 pages. Price, $2.50. loved Mr. Robinson's earlier story of the General Surgery, Ochsner, 625 pages, little Cumberland Mountain girl, whose Price, $2.50. bright courage won for her the affec- Eye, Ear, Nose and Throat, Wood, tionate appellation of "Smiles," will Andrews, Shamburg. 392 pages. Price, eagerly welcome her return. $1.75. "Smiling Pass" is fiction, purely, yet Pediatrics, Orthopaedic Surgery, Abt, it is fiction interwoven with facts, whose Ryerson, 306 pages. Price $1.75. authenticity is vouched for. And the These volumes maintain the very facts which the author has set down high standard of excellency achieved by are not recounted in any spirit of harsh the authors of Practical Medicine Se- criticism, but with all sympathetic ries which has come to be regarded as friendliness, and in the hope that those indispensable by the majority of prac- who may read this volume may come to titioners and specialists. a fuller understanding — and be charita- The entire series is published primar- ble, for he has lived among these, "our ily for the general practitioner, and at contemporaneous ancestors" and loves the same time the arrangement in sev- them. eral volumes enables those interested in In the story to which this is a sequel, special subjects to buy only the parts the mountain child. Rose — whom men they desire. called "Smiles" — courageously fought her way out of the shadows which in- nfHE LIFE OF JACOB HENLE. By; vest life in those isolated hills. It is Victor Robinson, M.D., Editor of the story of an individual, simply. Here- "Medical Life." in Smiles turns her face again to her The first biography in the English beloved mountains to help those others January, 1922. MISCELLANEOUS 55 who "hain't never hed no chance" to help themselves. Marriage is not the end-all of ro- mance and in this further story of her life "Smiles" is "the center of a new drama, more virile, more stirring than that of her childhood, for the life- threads of several strongly conflicting characters are closely Interwoven with her own. We wish to acknowledge also with gratitude the receipt of the following complimentary copies from the Page Company, Boston, Mass. : Famous Leaders of Industry, Second Series, by Edwin Wildman. The Sieve, or Revelations of the Man Mill, by Feri Felix Weiss. Also from The Critic and Guide Com- pany, New York City, Woman from Bondage to Freedom, by Ralcy Husted Bell. "While there has been a certain amount of sentiment over the passing of the horse, which has become practically extinct in the city, the dangers of epi- demics have been greatly reduced, be- cause of better sanitary conditions. "Severe epidemics of typhoid and ma- laria, which formerly took such a huge toll of life, no longer are known." Dr. Hogland said that the women of the A. I. U., who comprise 30 per cent of the membership, in 27 years have contributed but 28 per cent of the deaths. A slight increase in deaths among men from 45 to 60 years of age has been counterbalanced by a more favorable showing among men in the earlier and later years, according to A. I. U. tables, Dr. Hoglan pointed out. FOUR YEARS ADDED TO LIFE. Columbus, Ohio. — The span of life of man has lengthened fully four years within the last quarter of a century, in spite of the extra hazards which have come with twentieth century progress. So declares Dr. George W. Hoglan, secretary of the American Insurance Union, which will hold its quadrennial meeting here September 20 to 22, in- clusive. "Within another generation the al- lotted three score years and ten will be a thing of the past," says Dr. Hogland, who bases this hopeful prediction on the mortality statistics of the A. I. U. "Improvements brought about in san- itation, the nation-wide anti-spitting fight and other vial steps forward have all contributed toward increasing man's longevity," he continued. MisK-ouri Nurses' Law — The new nurses' law passed at the last session of the Missouri legislature became op- erative, June 20. It requires every per- son nursing for hire to obtain a license from the Nurse Examining Board and creates a new division of nursing called licensed attendants. The preliminary educational requirements for registered nurses will be four years in a high school after July 1, 1928, but licensed at- tendants need have only an eighth grade certificate. Annual reregistration is re- quired so that the nursing resources of the state will be a matter of official rec- ord at all times. Nurses who are now practicing and registered must reregis- ter with the board before Jan. 1, 1922, or take another examination. In com- munities of 30,000 or less a nurse may practice for hire as a "licensed attend- ant" without specified educational qual- ification, on the certificate of a licensed physician. Such attendants cannot practice outside of their communities. The next annual meeting of the Tri- State Medical Association will be held February 22-23, 1922, at Norfolk, Va., with headquarters at the Monticello Hotel. 56 SOUTHERN MEDICINE AND SURGERY January, 1922 Table of Contents for January, 1922 Original Communications. Sanitation of the Rural Home, by H. L. Cook, M. D. 1 Empj'ema, by James W. Davis, M. D 4 Modern Obstetrics, by M. Pierce Rucker M. D. 5 Tlie Economic Problem of the Doctor, by Drs. D. W. and Ernest S. Bulluch and R. H. Davis 10 The Diagnosis and the Treatment of Dis- eases of the Kidney Pelvis and Ureter, by Byrd Charles Willis, M. D 13 Tuberculosis in Infancy, bv H. H. Harrison, M. D. 15 The Use of Bone and Fascia Grafts in the Reconsn-uction of Bones and Joints, by A. G. Brenizer, M. D. 18 The Social Responsibilities of Modern Med- icine, by Frederick R. Green, M. D 22 Armistice Day Address, by John Wesley Long, M. D. 32 The President's Address, Tenth District Medical Association, Murphy, N. C, Oct.. 1921, by F. L. Siler, M. D 34 Resolutions on the President's Address 37 Editorials To Memorialize General Gorgas 39 Norfolk Meeting of Tri-State Medical As- sociation 40 Department Editors Gynecology and Obstetrics, Robt. E. Sei- bels, M. D. 41 Urology, A. J. Crowell. M. D. 41 Mental and Nervous, Jas. K. Hall, M. D... 43 Eye. Ear, Nose and Throat, J. P. Matheson. M. D. 45 Orothopaedics, Alonzo Myers, M. D 46 State Medicine, L. B. McBrayer, M. D 47 Roentgenology, Robt. H. Lafferty, M. D 48 Hospital and Sanatorium, John Q. Myers, M. D. 49 News Items 50 Publications received 52 April 1922 Meeting of tKe NortK Carolina Medical Societ}? Wll be Keld in Winston-Salem Southern Medicine and Surgery Vol. LXXXIV CHARLOTTE, N. C, FEBRUARY, 1922 No. 2 CANCER OF THE LIP AND BUCCAL MUCOUS MEMBRANE* By William D. James, M.D., and Albert W. James, A.B., M.D. The Hamlet Hospital, Hamlet, N. C. Probably no field of malignancy has proved so hard to deal with successfully as that where the growth involves the lip or the buccal mucous membrane. A cancer of the lip at or within the muco- cutaneous junction presents the same conditions which make it as resistant to the various methods of treatment as one located well within the buccal cav- ity. Both are bathed with saliva, are irritated constantly by the tongue rubbed over them, and can not be im- mobilized to any degree on account of the activity of the facial muscles. If the growth is located on the lip with- out the muco-cutaneous junction and does not infiltrate into the substance of the lip deep enough to involve the small labial glands, it will respond readily to radium exposures. When there is in- volvement of the mucous membrane or where the growth is bathed with saliva, we have found that the condition is very refractory to treatment by means of surgery, Xrays, and radium, or a combination of these methods. Formerly, it was customary to re- move these cancers by surgical opera- tion, the dissection being made about one-half an inch from the carcinoma, in uninvolved tissue. After this block removal, the edges of the wound were sutured with silkworm gut. Carcino- mata of the lip and buccal cavity show a tendency to metastasis early, there- fore, the fat and glands of the sub- mental and submaxillary regions were removed at the time of operation. The precaution to remove the fat and glands of both sides of the neck, even though *Read before the Fifth District Medical So- ciety of North Carolina, Sanatorium, N. C, July 27, 1921. the carcinoma was distinctly to one side of the median line, was because of the cross lymphatic drainage of this area. According to DaCosta,' the submental, submaxillary, and cervical lymphatic glands are usually involved within three months of the beginning of the cancer. He cites a case of his own where they were found to contain carcinoma cells in less than three months after the origin of the carcinoma of the lip. "This involvement cannot be detected by ex- ternal manipulation in the earliest stages, hence it is not proper to con- clude that glandular involvement is ab- sent simply because it cannot be pal- pated.'" With the advent of the X-rays and radium in the treatment of malignancy, it was thought that these cases would respond to these measures. It has been our experience that cancers of the lip and the buccal cavity are very resistant to radium and X-rays, in fact, that the results are not at all satisfactory. As mentioned above, if the growth is on the lip and removed far enough from the muco-cutaneous junction that it is not kept moist with saliva and is not rubbed by the tongue, it will usually be cured with exposures to radium. Our method of handling these cases is to remove the cancerous area by electro-dessication, using the technique of Dr. W. L. Clark, of Philadelphia, Pa. The machine is a high-frequency outfit, with special modalities, made by the Wappler Electric Company upon speci- fications furnished by Dr. Clark. The tissues for about one inch about the carcinoma are blocked with a one per cent solution of novocaine. Using the bipolar D' Arson val current, with the pa- tient reclining on the body electrode, which is eighteen by thirty-six inches in size, the operating electrode is in- serted into the normal tissues at a dis- tance of one-half an inch from the car- cinoma at intervals of one-eighth of an inch until the growth is circumscribed. 58 SOUTHERN MEDiCINE AND SURGERY February, 1922. The electrode enters the tissue to such a depth that the operator is sure that he has gone well beyond the base of the cancer. In the removal of a can- cer of the lip, the electrode is first in- serted from the external aspect for a distance about two-thirds of the way through the lip, in a crescentic line about the cancer and at a distance of one-half an inch removed from it. Then the lip is everted and a like procedure on the inside of the lip is carried out. If the cancer is within the mouth, for example, on the inside of the cheek, the same procedure is done of inserting the electrode into the normal tissues all around the cancer to the desired depth. Then the electrode is inserted into the cancer itself at short intervals until the whole mass is dessicated out to the line of circular dessication. The mass of tissues which has been dessicated is then lifted up with tenaculum forceps and removed with a sharp scalpel, the line of incision following the line of dessication. There is no hemorrhage, as the blood vessels and capillaries have been sealed off by the dessication proc- ess. A word should be said here in expla- nation of what the dessication method is. It must not be confused with any process of cauterizing or burning. At all times the operating electrode is of the same color and remains at room tem- perature, even though the milliamper- age being used is sufficient to devitalize bone or cartilage. As this process is one of direct diathermy, a certain amount of heat will be generated in the tissues to which the operating electrode is applied. This heat generated within the tissues will in turn raise the tem- perature of the electrode to a small de- gree, but it never becomes hot. Imme- diately upon removal from contact with the tissue, it may be felt as slightly warm. Emphasis is laid upon this fact, for many have a mistaken idea about electro-dessication treatment of neop- lasms, thinking that it is synonymous with cauterization. After the area is dessicated, it does not present a black- ened or charred appearance. The oper- ating electrode, thousrh a blunt instru- ment, is pushed readily through normal tissue and leaves a bleached, pearly, dessicated zone for a quarter of an inch upon each side. When the mass of des- sicated tissue, including the malignancy, is excised with a sharp knife, there is not a particle of oozing or bleeding along the line of incision. The blood vessels, capillaries, and lymphatics are sealed off by the dessication. We do not think it advisable to dis- sect out and remove the fatty tissue and glands of both sides of the neck. The lips, face, and buccal cavity have a very abundant lymphatic supply. In view of this fact, it is not wise to remove a few glands and not be sure that all are removed, because the resulting chances of rapid metastasis from the stirring up of cancer cells over a vast network of lymphatics are too great. The close relation of the lymphatic glands of the submental and submaxillary regions with the lymphatic glands of the super- ficial and deep cervical lymphatic chains is too likely to cause rapid metastasis if surgical measures are instituted as a safeguard against recurrence of the carcinoma in the neck. The anterior neck area from the inferior maxilla to the clavicles is treated pre-operative and post-operative with heavy doses of ra- dium and X-rays, in the hope of de- stroying the embryonal cells of a mic- roscopic metastatic growth before it is large enough to be palpated. All surgi- cal procedures in cancer of the lip and cancer of the buccal mucous membrane are contraindicated. The matter of ex- cision of the dessicated area is the re- moval of devitalized tissue for the com- fort of the patient, because it would slough away in a few days. References 1. DaCosta. John Chalmers, Modern Sur- gery, 1917 edition, page 923. 2. Dacosta, John Chahners, Ibid. FOCAL INFECTION* By Dr. R. E. Lee, Lincolnton, N. C. I sincerely believe that focal infec- tion is one of the biggest subjects that has been brought to the attention of the medical profession in the past sev- eral years. I also believe that the sub- ject is far from being exhausted at the present time. It is a subject that will and should interest every branch of our profession, and also should bring the two professions of medicine and dentis- "Read before the Caldwell-Catawba-Lincoln County Medical Society Hickory, N. C, Octo- ber 18, 1921. February, 1922. ORIGINAL COMMUNICATIONS 59 try into a closer relation to each other than ever before, and makes the otolo- gist and rhinologist indispensable to the general practitioner. The importance which focal infection plays in the causation of systemtic dis- ease is becoming more and more ap- parent each day. A list of the diseases in which the relation has been definitely established and those in which foci of infection are thought to be important etiological fac- tors, would cover a great many disor- ders, and nearly every organ in the body would be affected. Among the diseases whose definite relation to fo- cal infection has been definitely estab- lished may be mentioned acute and chronic rheumatism, neuritis, acute and chronic nephritis, cardio-vascular dis- eases and arthritis. Focal infection is suspected to be an important etiological factor in appendicitis, gall bladder in- fection, goitre, some of the skin erup- tions, anaemia and bronchial asthma. We are indebted to Rosenow, Billings, Shotmuller and several other workers for calling our attention to this subject. Rosenow called attention in an article in "The Journal of Infectious Diseases" for January, 1914, to the fact that the acute conditions are not so important, and emphasized the fact that the chronic conditions may remain unsus- pected for a long time, and it is the so- called blind abscesses and granulomata, which seldom give rise to noticeable symptoms, that favor the continuance of bacteria in the foci, which gradually increase in size and slowly produce ab- sorption and disease of the adjacent bone structure. In the Journal of A. M. A. for September. 1916, Irons gives some very interesting data on this sub- ject. In patients with arthritic condi- tions, 76'; had alveolar abscesses. In the group of cardio-renal diseases 47'; had alveolar abscesses. Bad tonsils were found in 40' ; of the arthritic cases and 24'; of the cardio-vascular cases. The principal regions in which we find foci of infection are the teeth, tonsils, the nasal accessory sinuses, i. e., mas- toid and maxillary, and genito-urinary tract, and it is essential that all of these regions should be examined in our obscure cases, and not merely examine the teeth and tonsils. When one real- izes that in the frontal sinus, the an- trum, the nasal passages, the eustachian tubes, the pharynx and larynx and their adnexia, there is about two square feet of mucous membrane which is more or less infected all the time and seriously infected often, one is inclined to dis- count the tonsil and teeth factor some- what and to wonder whether or not some of the foci that give so much trouble might be unrecognized in look- ing alone at the tonsils and teeth. Most of the infections are located about the teeth or lymphatic tissues of the head or neck. The teeth are more often at fault in adults, while it is gen- erally the tonsils in children. Then, too, what might be said about the rest of the body? What will a cold abscess do as regards focal infection, or an en- cysted pus pocket, an encapsulated tu- bercular center, or an undrained psoas abscess? Confined pus is always bad and does not always burrow its way- out, and I believe it often causes arth- ritis, just as gonorrheal arthritis is in- duced. The abdomen and pelvis not infre- quently hold circumscribed areas of in- fection in the gall bladder, appendix, uterus, fallopian tubes, seminal vesicles, prostate gland, bladder and ureter. Metastatic dissemination has often been observed to follow infection be- neath the toe and finger nails. Author- ities also report cases seemingly origi- nating from cases of bronchiectasis. From the above it is quite obvious that foci of infection, or circumscribed areas of pathogenic tissue, may be lo- cated in innumerable places. Often sev- eral such areas are simultaneously pres- ent, a fact which should be borne in mind in instituting treatment for the purpose of extirpating these disease spreading foci. The foci consists of areas of pathogenic tissue containing bacteria, ferments, exudates, and detrit- us of destruction. Owing to either in- creased pressure of the contents, low- ered bodily resistance (local or general), or injury, dissemination of either bac- teria or their toxins, or both, take place periodically or constantly in a mild de- gree. Preceding the spreading, a change in the virulence, type or special patho- genic properties of the germs may oc- cur. That this change or transmuta- tion mav and does occur, has been dem- onstrated by the epoch-making work of Rosenow. Cultures of the streptococcus viridens are taken and subjected to dif- ferent degrees of oxygen tension, to grow on various hypo and hypertonic 60 SOUTHERN MEDICINE AND SURGERY February, 1922. media and to animal passage; by this better without treatment, and even de- method the streptococcus viridans can preciating the suffering of those same be transformed into a typical pneumo- patients, because of either indifference coccus, as shown by cultural character- or ignorance. There are many chronic istics, biological reaction and the spe- invalids whose invalidism may lay at cific lesions produced in animals. Rose- the door of physicians who have been now has isolated different strains of careless about investigating the mouth streptococci which have exhibited spe- or other parts of the body for the cause cial affinities for different tissues of of the trouble, and taking little or no the body. One type when injected into trouble in finding a real method of re- rabbits produces uniformly an arthritis ; lief, preferring to give the usual drugs another amyostitis, another endocardit- that have been used from time imme- is. In fact streptococci have been differ- morial. entiated to such an extent that they It is not my intention to give the im- produce with almost uniform regular- pression that all cases can be readily ity, respectively, arthritis, endocarditis, traced, for that is not the case. It is nephritis, chorea, appendicitis, chole- a well known fact that many infections cystitis, myocarditis and erythema can be traced with the greatest diffi- nodosum. culty, but this does not excuse one from Somewhat of a revolution has taken making the effort, place in our ideas as to the etiology of 1. The teeth: The X-ray is abso- peptic ulcers. It is now known beyond lutely essential in the examination of doubt that in most cases these ulcers the teeth for alveolar abscesses and are produced by a metastatic infection should be used in every case where in the gastric mucosa by a certain strain there is the least doubt. The study of of streptococci. Rosenow, with one of focal infection shows that the dentist is his strains of streptococci, produced no longer concerned solely with the re- regularly peptic ulcers in animals, which pair, treatment and replacement of may occur within 48 hours after injec- teeth. He is concerned more seriously tion. with his patient's health and life. While great stress has been laid upon Much can be done in the prevention the streptococci, these are not the only field. Every one should be taught to germs found in focal inflammations that have his teeth regularly examined by a cause trouble in other parts of the body, competent dentist. Upon examining The staphylococci, tubercle bacilli and the teeth one is often struck with the gonococci play no small part in the number of dirty mouths, with Riggs dis- maintenance and dissemination of dis- ease and the gums full of pus. ease in the body. When you find bor- The treatment of oral infection is der line cases that you cannot satisfy both prophylactic and curative. Pro- yourself that focal infection is the phylactic should commence at birth and cause, a blood examination may be of be continued throughout life. Proper some value and in the differential count breathing is essential and any patho- an increase in the polymorpho nuclears, logical condition that interferes with from 65% to 72';;c over, indicates infec- nasal breathing should be corrected, as tion. mouth breathing is an important fac- Treatment ^*^** ^" °^^^ sepsis. Cavities should be promptly and properly filled, and a den- Naturally the treatment for pus any- tist should be consulted at regular in. where in the body is to get rid of it. I tervals. All teeth that are beyond sav- have no intention of going into the ing, such as teeth bearing abscesses, or treatment of the various diseases, per a tendency thereto, should be removed se, that may be caused by focal infec- at once. After removing the teeth the tion, nor do I wish it to be understood cavity should be thoroughly curretted that I think the removal of the foci and treated with iodine. In connection will alone cure. It simply removes the with the teeth we should consider in- cause and then a chance is given to fections in the antrum, as 15'', of these cure the serious diseases. We find come from diseased teeth. If careful many physicians today still treating examinations are made we will often such so-called diseases as rheumatism find that the apices of one or more empirically, telling patients that their teeth project into the antrum, conse- rheumatism and neuritis will soon get quently abscesses at the apices of such February, 1922. ORIGINAL COMMUNICATIONS 61 teeth would subject the antrum to in- fection and we cannot cure the patient by simply treating the teeth. Bollin- ger states that the maxillary sinus is more frequeuntly affected singly than any of the other sinuses, because in one- half of the cases it is infected from the teeth rather than from the nose. Whereas the other sinuses receive their infection only from the nose. When there is no necrotic bone in the antrum and it is not filled with polyps, drain- age through the alveolar process is usually sufficient, but when either of these conditions exist, it is best to do a radical operation. The tonsils play almost as important a part in causing focal infection as the teeth, as their structure is especially suited to retain infection, and still show little or no evidence, they are frequent- ly overlooked. When the tonsils are very much en- larged the presence of tonsilitis is easily determined, but an enlarged tonsil does not always mean an infected tonsil. We often see tonsils in children that dis- tinctly project into the pharynx, and do not advise their removal when su- perficial and do not lie imbedded be- tween the folds of the soft palate. In adults large tonsils should always be removed, as they should have under- gone retrograde absorption before adult life and only infiammation would cause them to retain their abnormal size. When tonsils are imbedded they may be explored by a hook made out of a bent probe, especially if the patient is made to gag, as gagging tends to protrude the tonsils into the pharynx and it is easier to explore the pockets for cheesy secre- tions, which indicate chronic inflamma- tion. When it is found that the surface of the tonsil and the anterior pillar is con- gested, more so than the remaining mu- cous membrane of the pharynx, you may feel reasonably certain that there exists a state of chronic inflammation. Indications for Removal of Tonsils 1. In children when large enough to interfere with respiration. 2. In children who have suffered from a serious sy.stemic infection, such as endo-carditis, or an acute nephritis fol- lowing an attack of tonsilitis. 3. When there is a cervical adenitis and the tonsils show evidence of either acute or chronic inflammation. 4. In all cases where there is a his- tory of recurring attacks of tonsilitis. 5. In all cases where the tonsils are chronically infected, shown by conges- tion about the tonsils and the presence of cheesy concretions. In adults the removal of the tonsils should be advised : 1. In all cases where there is a his- tory of recurrent attacks of tonsilitis. 2. In cases in which the tonsils show signs of chronic inflammation, especial- ly where there has been some systemic infection. 3. In cases which show marked evi- dence of chronic inflammation, even though the patient has no systemic in- fection or local discomfort. 4. We cannot promise the patient that removal of the tonsils will always cure a systemic infection, but we should explain to him that the chances are that his condition will be improved by this process. This will also apply to all other infection, as the antrum and teeth. PUERPERAL SEPTICAEMIA Farran Jarboe, M.D., F.A.C.S. Greensboro, N. C. The boundary line between physiolog- ical and pathological puerperiums is rarely sharply defined, so in order to avoid latter, prophylaxis should be the watchword and armed expectancy the attitude of every physician that has to deal with women during the puerperal state. The term *'child-bed fever" may still suffice for the layman, but to the physician it has but one meaning, Sep- ticaemia, blood poisoning, wound infec- tion or the absorption of toxms, from retained placental tissue, made septic by an added infection. It is possible that puerperal infection has occurred as long as children have been born, as it was repeatedly referred to by many of the ancient writers. In 1847, Semmelweiss, observing the frightful mortality in puerperal women made all of the attendants in the Vi- enna Lying-in Hospital wash their hands in chlorin water, and had the expectant mothers given an external bath with the same solution, by so do- ing he reduced the mortality from ten to one per cent. His theories were not generally accepted, however, and it was 62 SOUTHERN MEDICINE AND SURGERY February, 1922. not until the time of Lister and the ad- slow pulse is incompatible with sepsis, vent of Bacteriology, that the Patho- a rapid pulse is a danger signal, either genesis was properly understood. of hemorrhage or sepsis. After thirty- We are told that infection may de- six hours danger from hemorrhage is velop by one of three channels: air in- practically at an end, so that if on the fection, from the patient herself or third or fourth day the temperature re- auto-infection, and material introduced mains elevated, and the frequency of from outside sources capable of produc- the pulse is increased mischief of a sep- ing infection. Atmospheric contamina- tic nature must be suspected. The so- tion, while a comforting belief since it called milk fever theory which tempo- casts its responsibility on nature, is not rarily eased the conscience of our pre- tenable, since we know that women that decessors, as we know today is not rec- have been delivered in a strictly aseptic ognized since the lactation in a healthy manner have themselves developed woman is not accompanied by constitu- some of the air borne infectious dis- tional disturbance. We should not over- eases with absolutely no influence on look intestinal absorption about this the puerperal state. time, as very frequently the alimentary Auto-infection, which was formerly tract has not had much consideration, believed to play an important role in If a laxative does not clear the scene, this condition, we know today is as and we are able to eliminate all inter- equally impossible as atmospheric in- current disease, we are very certain to fection since we have learned that spon- have a septic condition to deal with, taneous generation of disease in the The foci of infection may be at any human body is not possible, so that we point in the birth canal, but in the vast are left with only the third condition as majority of cases septicaemia emanates a causative factor or infection intro- from the uterus. The lymphatics have duced from outside sources. either absorbed the poison directly or The origin or the manner of the in- a decomposing mass lies in the cavity, fection cannot always be determined, and becomes infected, producing at first but we are safe in saying that when a a sapraemia, and secondly, a septicae- sepsis develops following labor some mia. Too much stress should not be one of the attendants are culpable. put on the character of the lochia. In the birth canal, as elsewhere, Foetor is only a sign of decomposition, wound infection may be caused by any and accompanies sapraemia, while a one of a large number of micro-organ- diminished flow or stoppage may be due isms or the infection may be of the to a lessening of the secretion, or steno- mixed variety, two or more organisms sis of the internal os with consequent being present. We should bear in mind retention, and stagnation. In this con- that puerperal sepsis is not a specific nection, then, we must remember that disease, and that no specific organisms the most acute type of sepsis may be is concerned, but as in general surgery absolutely unassociated with foul smell- the streptococcus is by far the most ing lochia, and especially in those due constant offender. The gonococcus to streptococcus infection there is very plays an important part in the produc- little, if any, odor to be noted, and its tion of puerperal infection probably absence, therefore, is not necessarily a next to the streptococcus, while the favorable indication, but rather the re- staphylococcus must be reckoned with verse. We have said that in a majority in a great number of cases. The pneu- of cases the infection started in the mococcus colon bacillus and diphtheria cavity of the uterus as a putrid endo- organisms are occasionally met with, metritis or as a septic endometritis, the but by no means as frequent as the further course of the disease depends first three mentioned. upon the virulence of the offending or- As a rule septic infection begins to ganism. In some cases the general con- manifest itself in from thirty-six to dition becomes rapidly worse, and the forty-eight hours after delivery. Chill patient dies in a few days of a pro- is by no means a constant preceding found toxaemia. The uterus, being very factor, occasionally, even though the relaxed, offers no resistance to the woman has one it is passed unnoticed, passage of the micro-organisms through The pulse rate as a rule affords most the muscular walls by way of the di- valuable evidence of alteration in the lated lymphatics producing a metritis, smooth course of the puerperium. A peri-metritis, or pelvic peritonitis. The February, 1922. ORIGINAL COMMUNICATIONS 63 continuity of the endometrium carries mal of the temperature, and improve- the infection into the tubes and ovaries, ment in the volume and character of occasionally developing a general peri- the pulse, tonitis. We have had a pyo-salphnx develop We have recently had two cases of in one case, but there was some ques- pelvic peritonitis following puerperal in- tion whether in this particular case fection which became localized, and a there was not an old latent infection ex- large quantity of pus was liberated from isting prior to labor. The pus tube was the Cul-de-sac of Douglas. removed, and the patient made an un- In the management of puerperal sep- eventful recovery. In all the cases the sis we are confronted with many and convalescence was uninterrupted. The varied opinions. Probably no surgical drainage tubes were removed twenty- condition has had a wider range of ther- four hours after the temperature be- apeutic suggestions, varying all of the came normal and in no case did they way Irom drastic curettements, and pow- remain in longer than five days, erful antiseptic douches to the "do noth- ing policy." Personally, I am of the opinion that the middle ground is more reasonable, with removal of any infect- SURGICAL JUDGMENT IN OPERA- ed material that can be done without TION ON THE NOSE causing wounds or abrasions to the endometrium. Examinations, if made , • v , ^ir . ,1 r> t> i • u xt ^ , ,, u 1 1 u J i-u 4. Louis Nelson West, M.D., Raleigh, N. C. at all, should be done with extreme care, and then only to satisfy ourselves Probably no surgery is more gener- that there is no infected debris or pla- ally done today than surgery of the cental tissue retained in the uterine cav- nose and throat, and I think I am jus- ity. The general vitality of the patient tified in stating that no surgery mani- should receive our first consideration, tests greater inefficiency in judgment Salt solution by rectum and intraven- and technique. ously horse serum likewise given is of That so much has been written upon value. We are rather inclined to doubt this subject and so many instruments the utility of vaccines, and bacterins. devised for the performance of this Recently we have as a local treatment work, is prima facie evidence that in- in such cases used intra-uterine irriga- tra-nasal work is attended with difficul- tion with Dakin solution, and we make ties, if not with unsatisfactory results, mention of the fact only because our In view of the fact that this work is so results have been uniformly satisfac- generally done I am disposed to offer tory. The cases were all very similar, no apologies for presenting this paper, the diagnosis being carefully establish- The beneficial results that the patient ed. Unfortunately, owing to lack of hopes and the surgeon expects to be de- laboratory facilities at the time we were rived from an operation are far from unable to determine the infecting or- being attained in a large number of ganism. In only two cases did we find cases, while some patients are worse off any retained secundines, the others all than they were before they were oper- developing as a primary septic endome- ated upon. How, then, can this condi- tritis. The technique used was as sim- tion be remedied? The answer is this: pio as possible ; no instrumentation be- To treat a disease intelligently two fac- ing done except to be certain that per- tors are essential, namely, etiology and feet drainage was established by having pathology. The former treats of the the cervix thoroughly dilated. There cause of disease while the latter of mod- was several ounces of pus pent up in ifications and function and changes in the uterine cavity in three cases, be- the structure caused by disease. Once cause of poor drainage. After assuring these two factors are established the ourselves that the cervix was well open, diagnosis is automatic and the treat- a small Carrell tube was inserted all of ment a matter of routine. In the con- the way to the fundus, and another re- sideration of this subject, effort is made turn (low tube just within the inter- not so much to direct attention to any- nal OS, both were sutured to the lips of thing new in intranasal surgery but the cervix. The solution was used reg ularly every two hours. It was grati- -'Read before the Wake County Medical So- fying to note the rapid return to nor- ciety. 64 SOUTHERN MEDICINE AND SURGERY February, 1922. especially to consider the avoidance as far as possible of unnecessary surgery upon useful structures and most of all to urge greater care in the matter of rhinological diagnosis. Our science has not advanced far enough to warrant un- erring rules of accuracy in all cases, but far too often have we seen submucous resections of the septum turbinates re- moved and sinuses opened and drained without first trying to relieve the pa- tient by the simpler methods. We have all removed turbinates when the patient came for treatment com- plaining of nasal stenosis, and we have, I am sure, removed deviated septi to cure just such a condition when there was not a chance in the world to re- store the turbinated to a normal condi- tion. Many theories have been advanc- ed to explain the pathology of a deflect- ed nasal septum, but regardless of what theory you accept the fact remains that a deflected septum dates back to child- hood, and this is very important to re- member in taking the history of your patient. Too many septi are sacrificed because they are not straight. Nature models the interior of the nose so that it performs its function in spite of the deflection and I can not emphasize too strongly that a deflected septum does not require any operative intervention so long as the patient does not show symptoms of obstructive breathing and drainage. On the other hand, in a patient with obstructive breathing and drainage and a deflected septum it is not the septi in all cases that is the offender. Any im- perfect analysis of the subjective and objective symptoms and any neglect to examine all other intra-nasal structure as to their size and shape and color are the cause of the bad results that we all at times have. In reviewing the lit- erature on submucous resection it is advocated for almost everything, each writer states that it is the operation of choice because it does not destroy any tissue. This is all very true. It is the operation of choice in intra-nasal work and it does not destroy tissue, but it is not the only operation that can be done on the nose, and it is not indi- cated in all cases of nasal obstruction. We have all had patients that came for treatment on account of inability to breathe well through the nose, and on examination we find that the septi is deflected and the turbinates are en- larged. A submucous operation is ad- vised and performed and there is an uneventful recovery and you now have a straight septum but the patient can- not breathe any better. Where, then, lies the fault? The etiology was not taken into consideration. Refer to your history if the case is one of yours and you will probably see that the patient told you that he had been suffering for two years, yet the deflected septum probably dates back to childhood, the turbinates may have been and probably are the real pathological condition. It is perhaps true that the diseased condi- tion of the turbinates were caused by the deflected septum but when the tur- binates are already diseased an opera- tion on the septum will not cure the condition. A submucous operation years before would have. On the other hand, turbinate bodies are sacrificed when the fundamental cause of the nasal symptoms under consideration may be due to a deviated septi infected sinuses, diseased tonsils, root abscesses or hypertrophied lym- phoid tissue in the naso pharynx, ter- tiary syphilitic manifestations and dis- ease or abnormal conditions of other structures causing turgescence of the turbinates must receive attention. If the cause of turbinate congestion is im- proper air, sedetary habits, constipa- tion, negative pressure from a deflected septum, it is obvious that turbinate sur- gery will fail to give relief, and unless it is most conservative will impair nasal physiology. In cases where the nose is narrow and the dialator muscles have atrophied from disuse due to a narrow nose and probably adenoid in childhood you will find that the inferior turbinates have swollen so as to completely fill the nose and the patient complains of inability to smell or taste, the septum here is possibly straight or nearly so, what, then, can we do to relieve this patient? Surely if we remove the turbinates we will have in future life a dry nose which is even worse than what we now have. In some of these cases you will find con- stitutional conditions, infected sinuses, etc., that when corrected will cause less congestion of the turbinates. Medici- nal treatment will relieve some, and a few, and I mean a very few, will have to have the anterior tips or the pos- terior tips removed. The patient is in- structed to use the nose more with the February, 1922. ORIGINAL COMMUNICATIONS 65 help that we have given him and if dry nose. Now, when this septum is necessary sleep with a bandage over removed the fibrous tissue that unites his mouth and in a very short time he the two flaps obhterate all of the blood will recover some of the lost dialator vessels and glandular structure of the muscles and the tonic effect of nasal septum with the resulting dry nose on respiration will cause further shrinking both sides, you have a straight septum of ihe turbinates. but your patient will not use either side. Pressure of the middle turbinates From this resume of conditions and against the septum and catching the few illustrations we may conclude the Olfactory nerve filaments is perhaps the fallowing: chief cause of impaired smell, but it i. That not all deflected septi require should be remembered that in a large correction. percentage of these cases pressure is 2. That the turbinate bones should be primarily due to a deviated septum saved and not subjected to surgery until high up and the submucous operation we can absolutely prove that it is the is the indicated surgery, not turbinec- turbinate and not constitutional condi- tomy. tions or reflex conditions causing the Operations on the nose when sinus pathology, infections are present should be avoid- 8. When deflected septi and Hyp. tur- ed as much as possible and operations binates are accompanied by chronic in- on the acutely infected sinus should be fections of the sinuses the sinus and limited as much as consistent with se- not the septum should be operated curing sufficient drainage on account of upon, not the septum and turbinates to the spread of the infective process, give drainage as is often done. The virulence of the infective bacteria 4. Operations should be avoided as usually becomes exhausted in about far as possible in all cases of atrophic three weeks and a radical operation may conditions of the nose, be done with greater safety. 5. Finally, the decision to operate or In operations on the nose and cor- not to operate is controlled by one's own recting deformities resulting from conscience, as indicated by the symp- syphilis, the surgeon should always take toms produced by the pathological con- into consideration the pathology of the dition the patient exhibits, locally and disease. The fact that bone and car- constitutionally, and further after a tilage are the tissues usually involved complete history and a thorough exam- in these cases and the poor state of ination before and after the use of co- health in which these patients are gen- caine and adrenalin, erally found, syphilitic deformities of the nose cannot be corrected without first combatting the destructive influ- PAROXYSMAL TACHYCARDIA* ence of the disease and restoring as far j ^^lonison Hutcheson, M.D., Richmond, Va. as possible the general health of the patient. Bone transplantation in syph- One of the known disorders of the ilitic subjects is distinctively contra-in- heart beat, that form commonly called dicated. paroxysmal tachycardia or paroxysmal Another class of cases that all sur- auricular tachycardia, is generally re- geons that do nose work have but never garded as being relatively rare. The want is atrophic rhinitis. In nearly all condition is an extremely interesting- cases if the atrophic condition is on one and comparatively easy of recogni- one side only we will find that this side tion by ordinary chnical methods, pro- is very wide and that the septum is vided its salient features are clearly deflected to the other side these cases kept in mind. I have thought it worth nearly all come to a submucous opera- while on this occasion to review briefly tion with the almost certain results of the history and findings in several cases having the same condition to follow of paroxysmal tachycardia that I have very soon on the well side. Ask the recently had the opportunity to study, next patient that comes into your office and to discuss the more important con- suflfering, as I have stated, which side siderations in the diagnosis, prognosis of his nose he breathes best through and treatment. and he will tell you the one that is al- most closed. Why? Because it is al- *Read before the Southside, Virginia, Medi- most impossible to breathe through a cal Association, September 13, 1921. 6G SOUTHERN MEDICINE AND SURGERY February, 1922. It may be well to recall that, under as perfectly regular and approximately normal conditions, the cardiac rate of 200 per minute. Pressure over the approximately 72 beats per minute is right vagus resulted in prompt cessa- determined by the pacemaker which is tion of the tachycardia and a return to situated in the sino auricular node at a normal rate of 70 per minute. Ex- the junction of the superior vena cava amination showed an enlarged heart, and the right auricular appendage, high blood pressure (S. 192, D. 104), From this point the impulses to con- and signs of pulmonary and hepatic con- tract spread through the heart cham- gestion. On rest and digitalis the com- bers, following a definite pathway pensation was quickly restored and sub- through auricle, auriculoventricular sequent investigation revealed a gastric bundle and ventricle. The pacemaker is anacidity. On regular doses of HCl the subject to certain known influences diarrhoea disappeared, and no further which increase or diminish the heart's attacks of palpitation occurred during rate, as, for instance, stimulation or de- the three weeks she was under obser- pression of the vagus. When, however, vation. the origin of impulses escapes from the Case 3— A lawyer, aged 32, was seen control of the pacemaker, extremely ab- May n, 1921, having been referred by normal rates and sequences occur, a his physician for cardiac investigation, notable example of which are the seiz- He had had attacks of rapid heart ac- ures of paroxysmal tachycardia. Dur- tion off and on for ten years, but dur- ing these attacks, some part of the wall jng that period had served in the army of the auricle appears to become irrita- and been shot through the right lung, ble and temporarily takes over the func- xhe attacks would begin and end ab- tion of pacemaker, producing a new rate ruptly, and at the onset there was a greatly in excess of the normal but en- sensation as if his heart stood still, tirely regular m rhythm. At autopsy The rate was said to have been as high no characteristic lesions are found. as 225 per minute. General examina- Case 1 — White, male, aged 58, far- ^ion was negative, and cardiac examina- mer, was seen Feb. 9, 1921. He com- tion showed a normal heart. Electro- plamed of spells of palpitation which cardiograms revealed only a slight sinus had occurred at irregular intervals for arrhythmia, while the orthodiagram 25 years. His heart would apparently gave no evidence of increased size, stand still for a beat then start off at ^ase 4-A physician, aged 59 years, a rapid rate which lasted for a variable ^^^ examined August 6, 1921. He had ^ngth of time and then ceased abruptly. ^^^^^^^ ^^^^ ^^^^^^^ ^^ palpitation for ten years and these were characterized During the attacks was "uncomfortable in his chest" and somewhat short of ^ ^^^ sensation of brief cardiac stand- breath but could get around to attend ^^jjj f^^owed by increased rate and ab- to his busmess His physician reported ^^ ^ termination. Rates of 180 to 200 ?^^ ^" ^^, ^^^^"^ ,^^^ pulse rate was J ^j^^te had been noted. There had "over 170." General examination show- been no symptoms of cardiac failure. ed moderately thick vessels with low ^^^ ^ ^^^ ^^^ ^ jl^ ^^ palpitation blood pressure (S. 102, D. 68 ) The ^^^.^^ J^^^^ lasted less than L hour heart was slightly enlarged to the left j^^ ^^^ ^^^^ perfectly well. Thorough and the electro-cardiogram indicated examination was entirely negative, left ventricular preponderance. Rhythm ^ ;- * , -^ ^ & , ^„ between attacks was perfectly normal. Case 5— A white woman^ aged 42, Case 2— White woman, aged 78, seen T^'\^^^",^"^"«J .^^1 l^^l For 20 years April 30, 1921. Her chief complaint she had been subject to attacks of rapid was palpitation which she thought sec- heart action, m which the rate seemed ondarv to a digestive disturbance char- to change m one beat, becoming so fast acterized by flatulence and diarrhoea, that it could not be counted and then Her palpitation had, for 15 years, come -Hist as suddenly returning to normal, in attacks which lasted from a few min- during the attacks she was uncomfort- utes to 24 hours. They began and end- abl^ conscious of her heart but could ed suddenly, and were accompanied by ^a^ around. Between attacks she was a sense of extreme precordial fullness ^^ite comfortable. Examination show- but very little dyspnea and no pain. On ed a thm individual with obvious vis- admission to the hospital she was in ceroptosis, but otherwise healthy or- an attack and the pulse was recorded gans. She had been troubled with con- February, 1922. ORIGINAL COMMUNICATIONS stipation, and treatment for this was advised. A consideration of the foregoing cases brings out the fact that paroxys- mal tachycardia may occur at practi- cally any age, the onset in this series being from 22 to 63 years. It is also seen to be present in several types of individual and to accompany no special variety of cardiac pathology; while thorough search for systemic disease, which included blood Wassermann in all cases, revealed nothing that could be considered as significant. It will be observed that the character- istic feature in the description given by the patient of the attacks is the sudden onset and equally sudden termi- nation. In one beat the heart rate changes from normal to two or three times normal and resumes its normal rate just as abruptly. Examination during an attack shows a perfectly regular heart, and there may be absolutely no sign of cardiac disease other than the extremely rapid rate. Between attacks patients are en- tirely comfortable, and cardiac exami- nation is frequently absolutely nega- tive. Elecrtocardiographic examination during the attack explains the produc- tion of the tachycardia, while between attacks it gives no information what- ever. Paroxysmal tachycardia may be con- fused with auricular fibrillation or au- ricular flutter, and the differentiation from these conditions is of great im- portance as regards treatment. By graphic methods the distinction is read- ily made, but as a rule it can be arrived at without these. Auricular fibrillation or delirium cordis is a common disorder and may give rise to extremely rapid heart rate, yet the pulse beats irreg- ularly in force and time, and there is usually a distinct difference between the pulse and apex rates. When one is satisfied that the apex and radial beats are regular in time and correspond numerically, fibrillation may be ex- cluded. Auricular flutter bears some resem- blance to paroxysmal tachycardia and can be finally differentiated only by graphic studies. It is not nearly so common, however, as either auricular fibrillation or paroxysmal tachycardia. The auricular rate may be as high as 350 per minute, but there is also pres- ent a partial block which cuts down the ventricular rate appreciably. The prognosis in paroxysmal tachy cardia is, as a rule, good. Patients rarely die in the attacks, and seizures have been known to occur at variable intervals for many years. In the ma- jority of cases that have been followed, however, the final termination came as the result of myocardial failure. I would mention here a patient whom I first examined in 1918. She was then 61 years of age and gave a typical story of attacks of paroxysmal tachycardia which had recurred for years. The ex act date of onset of the attacks was not known, but she recalled having spells with her heart off and on since the age of twenty. She continued to have the attacks of tachycardia and later devel- oped auricular fibrillation, death occur- ring in June, 1921, following a stroke of apoplexy. The attacks in this pa- tient apparently kept up for fifty years. The attacks of paroxysmal tachycar- dia are often terrifying to both the pa- tient and his family, and much needless anxiety may be avoided by thorough explanation of thei*" nature and prob- able outcome. Unless there is, in addi- tion, some other evidence of cardiac im- pairment, radical restrictions should not be made in the manner of living on account of the attack per se. Where the seizures come in rapid succession, regular doses of bromides or chloral often seem to modify their frequency and severity. Digitalis has no effect either direct or indirect on the parox- ysms. During the attack, it is better for the patient to remain quiet, and, if his seizure is prolonged more than a few minutes, to have a sedative, preferably chloral hydrate. Various manoevers such as inverting the body by hanging out of bed, inducing vomiting, holding the breath, drinking cold water, etc., have in certain cases seemed to give re- lief. The most generally effective meas- ure, however, is stimulation of the va- gus, which is said to terminate the pa- roxysm in more than half the cases. This may be attempted by having the patient hold a deep breath, or, better, by direct pressure over the carotid ar- tery until that vessel is obliterated, or, when these measures fail, by prolonged pressure over the eyeball. 68 SOUTHERN MEDICINE AND SURGERY February, 1922. PRIMARY SARCOMA OF THE APPENDIX By Hyman I. Goldstein, M.D., Camden, N. J. Case Report — Miss Lena G., 25 years of age ; white girl. Resides in Camden, New Jersey. F. H. negative, worked in pen factory for a number of years. I was called in to see her for the first time on September 29, 1919, at 10 P. M. She said she was an inspectress of pens and was piercing the slits and cuts in pens for eight years. She was always very constipated and had "stomach and bowel" complaints of several years. She had swollen feet and legs several years ago; had measles, "rheumatism." Lost 23 pounds in the past two years, most of it during past few months. Her best weight was 123 pounds, now weighs only 100 pounds. She has had several similar attacks of "appendicitis," with severe pains, abdominal cramps and vomiting during the past four or five years. Present attack of "pain in the stomach" and vomiting began two days ago, and a physician who was first call- ed in, diagnosed the case as acute ap- pendicitis. The vomiting was persist- ent and severe, and the pain become worse. Abdomen was distended and rigid, pulse rapid, temperature 100.5 degrees, patient looked "very sick." There was a peculiar fullness and dis- tension in the upper abdomen, and marked pain and tenderness and rigid- ity very low down in the right iliac fossa. While the case gave all the ap- pearances of a severe acute appendicitis with probable abscess formation and adhesions due to previous attacks of inflammation in this region, yet it also looked like a typical case of acute in- testinal obstruction, with or without some acute inflammation, involvement of the right tube and ovary. I advised immediate removal to the hospital for operation. Patient and her family wanted to talk it over during the night, so I left the house. Early the next morning, September 30, 1919, I was ur- gently called on the telephone, to come to the house at once, as the patient was much worse, the pain more severe, and the vomiting constant. I found the pa- tient in bad shape, with markedly dis- tended and painful abdomen. I imme- diately arranged with Dr. Alfred C. Wood, of the University of Pennsylva- nia and Howard Hospitals (Philadel- phia) for prompt operation. Dr. Wood saw her within two hours after I left the patient's house, at the Howard Hos- pital. He also thought there may be intestinal obstruction with the diseased appendix. Under ether anesthesia. Dr. Wood opened the abdomen, and found the appendix diseased with a mass in- volving the appendix and the head of the cecum — the mass in the cecum could be distinctly felt, but was thought and hoped to be inflammatory in nature. Appendectomy was quickly done, as the patient was very weak, and cecum left untouched for the present. The gut was markedly congested and distended with gas, and forced outside of the incision. On searching for a possible obstruction, a thick band was found tightly con- stricting the gut low down in the right iliac fossa, and a foot of bowel was dark and quite discolored, the strip where the band was holding was nearly black and gangrenous; however, upon release of the band and the application of hot wet compresses, the color im- proved and as the patient was very weak. Dr. Wood and I felt enough had been done ; the distended gut was, there- fore, with some difficulty, replaced into the abdominal cavity and the wound sewed up, and the patient was returned to her private room. The appendix was sent by Dr. Wood to Professor Allen J. Smith, Pathologist of the Medical Department of the University of Penn- sylvania, and he made a very careful examination of the tumor and the re- port of lympho-sarcoma of the appen- dix was received from him (10/21/19) (Block No. 6239) and is here appended. The "mass" in the cecum cannot be felt at present. This was probably inflam- matory in nature, and probably not the same as the real tumor in the appendix. Patient is well and able to do her work, eight months after the operation. She has not regained her best weight, and is still very costive. She has no pains and feels "no masses." Has no cough or chest symptoms, no palpably enlarg- ed lymphnodes. She says she weights about 100 pounds, and has some abdom- inal distention when "her bowels don't move for a day or two." Her mother recently had an attack of biliary colic — she is 53 years of age and has had "gall stone trouble" for twenty years. I saw the patient and her mother May 26, and June 1, 1920. On January 31, 1921, February, 1922. ORIGINAL COMMUNICATIONS 69 sixteen (16) months after the opera- tion, the patient is well and working. Report of Specimen Examination Diagnosis: Lymphadenoid sarcoma of appendix. Section of appendix is proximal, thickened, portion above the tube here of approximately 1 c.c. in diameter, the thickening involving to some extent all of the circumference of the wall but particularly that half next the meso- appendix, which is over 5 mm. in thick- ness (that of the opposite side being about 1.5 to 2 mm. thick). The lumen in the section is open but compressed by the swollen side of the wall to a crescentic outline. Under low magnifi- cation (under a hand lens) the thicken- ing referred to seems due to a fairly defined mass under the broken mucosa, apparently involving both submucous and muscular coats and extending into a thickened mesoappendix. With high- er magnification this mass is found fairly sharply defined but not encapsu- lated, and to be comnosed of small round cells of lymphocytic type, not ar- ranged with any special architecture, infiltrating the deeper tissues but ap- parently partly limited by the overlying mucosa. At its borders the cells infil- trate the adjacent tissue of the sub- mucosa and deeper coats; and in its ex- tension through the wall it infiltrates the muscular coat irregularly. The musoca is relatively normal, bro- ken at one or two points by artefact and not ulcerated ; its glands of about normal size and showing a slight excess of goblet cells. Its follicles are large, solidly lymphocytic ; and at its base throughout the circumference there is a continuous excess of lymphoid cells, suggestively extending from the lym- phocytic mass above referred to. In the half of the wall not occupied by the nodula the submucosa is thickened, fib- rous but loose, with the node showing a narrow zone of infiltration on each border into the coat. The same is true of the muscular coat and of the fibro- serous tunic, but in the node itself the muscle can be traced, its fasciculi sepa- rated well by the lymphoid cells. The fibroserous coat is dense and slightly thickened at places, elsewhere thick and loose as from oedema ; and throughout contains a scattered excess of lympho- cytes. There is a second section of a loose fibro-muscular tissue (smooth muscle) which is believed to have been part of the mesoappendix, which does not show the structure of intestinal (colon or ap- pendix) wall. In this as well as in the fibroserous the lymphocytic for- mation is massively infiltrated in part of the tissue, the rest of the tissue showing a loose, rich infiltration by the same type of cells and small foci of the same elements. In studying this lymphocytic forma- tion it is to be recalled that it has formed in one or more nodules, not en- capsulated but with narrow zones of in- filtration at the borders, with scattered excess of the same type of cells through practically all of the sections, that it does not present the architecture of a normal or of an inflamed lymphnode, be- ing without follicles, and sinuses; that the cells are contained in a delicate lym- phadenoid reticulum. The cells are al- most all of the ordinary appearance of small lymphocytes, but scattered among them are larger lymphoid examples, and that at places there is the appear- ance of elongation of these cells into spindle form and small fibroblasts as if some degree of organization were pro- ceeding at such sites. There are, too, at places eosinophiles to be seen. The small mass is fairly vascular, the ves- sels of capillary type. From the above data the writer is satisfied that there is a chronic inflam- matory involvement in the changes of the appendix, but believes that the no- dular thickening on one side of the ap- pendiceal wall is not of inflammatory origin nor to be a lymphnode occurring aberrantly in this situation, but by ex- clusion has come to the view that it is a true tumor, a lymphadenoid sarcoma. Dr. Jos. McFarland, Dr. M. B. Hart- zell. Dr. F. B. Lynch, and Dr. D. L. Farley examined the slides and confirm- ed the diagnosis of sarcoma of the ap- pendix. Multiple Sarcoma Case Report — Mrs. Emma B., aged 72 years ; white woman ; widow. About six months ago (in July or August, 1920) she noticed a small lump over the left chest wall near the sternum. About six weeks later, it began to increase in size very rapidly, the lump itself gave her no pain ; for the past six months she has had pains in the left shoulder and chiefly in the left hypochondrium and left lumbar region. Some pain was 70 SOUTHERN MEDICINE AND SURGERY February, 1922. complained of in September, 1920, down per cent second hour ; total for two the thoracic spine and toward the front hours, 25 per cent. I made a diagnosis of the base of the chest, and around the of sarcoma with metastases, and abdomen in a girdle-like manner. The On October 10, 1920, she was admit- pains at times were very sharp, "like ted to the Hospital of the University of a tight-squeeze with hands pressed to- Pennsylvania, in the service of Dr. Al- gether." There was no headache and fred Stengel. no dizziness. Occasional cramps in the October 11, 1920: Blood Urea-N, 16 legs were noted. mg. ; plasma C02, 59 vols, per cent; When I first saw her, September 29, plasma chloride, 6.1 gms. per litre. 1920, she had a large (size of orange) Blood: R. B. C, 4,100,000; W. B. C, round mass over the upper part of the 8,400 ; Hb., 85 per cent, left chest about an inch to the left of Urine: Few hyaline and light gran- the sternum and extending outward for ular casts; no R. B. C, few (40-50) W. about three inches, toward the anterior B. C. ; no sugar ; faint trace albumin ; axillary line (left). She had an en- S. G., 1.020; triple and amorphous phos- larged cervical lymph-node below the phates. left ear. Many telangiectases were October 15, 1920: Blood Wasser- present over the arms, breasts, abdo- man, negative; 'phthalein output (Octo- men, left temple, and a few on the back, ber 11, 1920), 15 per cent first hour; The thyroid was very slightly enlarged. 15 per cent second hour; total, 30 per She had a slight cough, but no blood- cent, two hours (intramusc). stained sputum. The right scapula October 15, 1920: Urine, faint trace stands out more prominently than the albumin, no casts, no R. B. C, 2-5 W. left. Scoliosis present. B. C, S. G., 1.017, no sugar. She informed me that some doctors October 20, 1920: X-ray of left kid- had told her it was a "dilated blood ves- ney region was negative ; scoliosis and sel" (or protruding thoracic aneurism) hypertrophic spondilitis noted. (Dr. H. and "there is danger of this swelling on K. Pancoast and Dr. Prendegrast.) the chest bursting, and causing a fatal She was sent home from the hospital, hemorrhage." On September 30, 1920, and I saw her again (November, 1920), X-ray and fluorscopic examination by complaining of much pain over the left Dr. M. K. Fisher, of Philadelphia, show- base of chest (anteriorly) and over left ed no connection of this neoplastic mass hypochondrium, and she was unable to with a rib or the inside of the chest, sleep on account of this severe pain. Heart shadow was about normal, aortic necessitating the use of veronal, and arch, slightly dilated if any, and possi- even morphine hypodermically. Before bly, metastasis near the arch ( ?) . she came home from the hospital, Drs. Lungs: At this time were apparent- Pancoast and Prendegrast made an X- ly normal except for an indefinite sus- ray and fluorscopic examination of her picious area in the base of the right chest and found evidences of metastases lung. in lungs, and below (in the hollow) the Blood Wasserman: Negative (on re- aortic arch, peated tests). Nov. 7, 1920: She suffers a great Blood pressure: S. 190, D. 106. deal of pain in the upper left abdomen. (Auscultatory). Enlarged glands in the left axilla, the Heart: Systolic (transmitted to the thyroid and cervical glands are much axilla) murmur heard at the apex and enlarged from metastatic nodular over the left chest. growths. The mass over the upper left Lungs : Apparently negative, except chest is greatly enlarged, hard, nodular some impairment over the bases of both and firm, extending from the sternum lungs. to the left axilla. Urine: September 30, 1920, many There is a large distinct mass in the hyaline and Epithelial casts present. left hypochondrium — the pulsations of October 1, 1920: S 200-210/D. 100. the aorta are transmitted through this Complains of insomnia. growth. It appears to move somewhat 'Phthalein renal function test: First on respiration. This large tumor is hour, 5 per cent; second hour, 15 per either a retroperitoneal sarcoma, or a cent ; total for two hours, 20 per cent, miesenteric growth and even gastric in- 'Phthalein renal function test (second volvement being probable and possible, time) : 10 per cent first hour and 15 She may have other metastatic neoplas- February, 1922. ORIGINAL COMMUNICATIONS 71 tic nodules in parts and organs yet un- suspected. However, I am satisfied that the growth may possibly have been primary in the mass first seen on the anterior (left) chest wall. The patient has been seen by Professor Alfred Stengel, and his assistants, Dr. O. H. P. Pepper, Doc- tors Kern, Cook, Barrett, Arnett, and Miller, to whom I wish to express my thanks for the assistance and the clini- cal notes obtained from the study of this case. On December 21, 1920, the patient was readmitted to the Medical Ward of the University Hospital. December 23, 1920: Blood, R. B. C, 3,720,000; W. B. C, 6,600; Hb., 70 per cent; Polys., 83; Lymph, 12; L. M., 1; Trans., 4. Urine: Trace of albumin; few hya- line casts; 15-20 W. B. C. to high P. F.; triple phosphates; no R. B. C. 'Phthalein output, 25 per cent first hour; 10 per cent second hour; 35 per cent total for two hours; S., 185/D. 88. January 5, 1921: Blood urea-N, 15 mgm. ; plasma chlorides, 5.7 gm. per litre. January 13, 1921: Blood, R. B. C, 3,290,000; W. B. C, 6,800; Hb., 65 per cent. A large lymph node removed from the right side of the neck, below the ear, was examined in the Pepper Clinical Laboratory by Dr. Herbert Fox and Dr. David L. Farley, and they reported: "Sarcoma of the large round cell type." Report "Sarcoma, large round cell type, pre- dominating. Almost entirely cellular. Very little stroma. Lymphatic tissue practically replaced by new growth. Cells show large vesicular, hyperchro- matic nucleii with many mitotic figures. Cytoplasm scanty and stains poorly. Certain open spaces through tumor roughly lined with tumor cells suggest marrow spaces but this is not definite. Blood vessels poorlv formed." Dr. M. B. Hartzeil, Dr. Fred D. Weid- man, and Dr. Allen J. Smith saw the slide and confirmed the diagnosis of (large) round cell sarcoma. January 21, 1921: Dr. H. K. Pan- coast reports that the X-ray examina- tion shows mediastinal metastases. Ribs not eroded. Diaphragm on fluorscopic examination moves equally on both sides. Heart appears slightly enlarged. Patient is anemic, emaciated and weak. She is too sick to have a gastro- intestinal study made. For the past few days she has had some pain in the left breast. There is apparently a small metastatic nodule in the gland. The large mass in the upper left quadrant of the abdomen now extends about IV2 to 2 inches below the costal margin and over toward the mid-line. It is quite firm and somewhat nodulous and ten- der. The pain in the region of this growth is very severe. Aspirin, codeine, etc., failed to relieve her. So that opi- ates of a stronger character must now be used. 1425 Broadway. Bibliography 1. Kelly and Hurdon, The Appendix (Book), 1905. 2. Garnett Wright, British Medical Jour., London, July 22. 1911, II, p. 150. .3. G. A. Geist, Minnesota Medical Jour., St Paul, 1918, 1, 295-298. 4. Hugh Grouse, Surg. Gynec. and Obst., 1910, 11, 2, p. 457-466, No. 5. 5. Richard H. Harte, Trans. Anier. Surg. Assoc. 1908, Vol. 26, p. 399. 6. (D. H. A.) G. Neoplasm of Appendix, Guy's Hospital, Gazette, London, 1915, XXIX, 18:?. 7. T. Carwardine, British Med. Jour., II, 1771, 1907 (Case 1905). 8. Jones, Surg. Gynecolog. and Obst., XII, i;51-131. 1911. 9. C. A. Powers, Colorado Med., 1911, VIII, 21-24. 10. White and Whaland, Med. and Surg. Re- ports, Episcopal Hospital, Philadelphia, 1913, 1, 357-365. 11. C. D. Stewart (N. Y.), Ann. Surg., Phil- adelphia, 1908, XLVIII, 607-610. 12. E. E. Boyer: A Review of the Litera- ture, Amer. Jour. Med. Scs., 1919, CLVII, 775- 782. 13. S. P. Reimann: Primary Carcinoma of Appendix, Proc. Path. Soc, Phila., 1918, N. S. XXI, 7, Amer. J. Med. Scs., Aug., 1918, No. 2, Vol CLVL p. 190. 14. D. Symmers & Greenberg (M), Lym- phoid Hyperplasia of the Appendix, Jour. A. M. A., 1919, LXXII, 468-470. 15. M. G. Wohl, Sarcoma of Appendix, Ann. Surg., Phila., 1916, LXIV, 311-317. 16. L. Smit: Sarcoma of Appendix, Med. Rev., Bergen, Norway, 1916, XXXIII, 377. 17. Bernay, in Kelly, p. 450-451. (Reported by Kelly and Hurdon). 18. Vassmer, W. Deutsche Zeit. f, Chir. Leipzig, 1908, XCI, 445-490. "2 SOUTHERN MEDICINE AND SURGERY February, 1922. ing only pigmented areas which event- NEOSALVARSAN IN YAWS ually disappeared, leaving little or no trace. By Louis F. Jaggard, M.D. ]y[y experience coincides very largely Monieka, Coquilhatville. Belgian Congo, West with Pickett's. During the past two Central Africa. years I have treated about 250 cases and have used Neosalvarsan with most Frambesia, or tropical yaws, is a gratifying results. I find the prefer- spirochetal disease found in Central able way is to inject neosalvarsan by Africa, Malay Peninsula, the Philip- gravity and utilize a solution of from pines, Malaysia and the East Indies. It 100 to 140 c.c, made up in normal saline is caused by the treponema pertenue, solution. Sometimes on account of lack discovered by Castellani in 1905. The of time, I am compelled to utilize the spirochaete is found in the blood, in the drug in a glass syringe, giving a con- lymphatic glands and in the epidermis centrated solution. I pay particular at- of the granulomatous eruption. The dis- tention to slowness of injection, as I be- ease is regarded ordinarily as having lieve this is most essential in prevent- primary, secondary and tertiary stages ing reactions. and its incubation period is from a week Of the cases treated four or five have to three months. The primary stage returned with a recurrence of the dis- includes the period of incubation. The ease. It is very difficult to determine presence of the disease is indicated by whether it is a reinfection or a recur- malaise and headache, with articular rence of the original condition. In cases pains. The seat of the infection is in- of a mother and child I am rather cer- dicated by one or more papules and the tain that we are dealing with a rein- disease, which is transmitted by contact, fection, but in the other cases it ap- may either be genital or extra-genital, pears to be a recurrence, as I had treat- The secondary stage may come on a ed them at the very beginning of the few days after the appearance of the appearance of the eruption, initial lesion or it may be extended for I have seen a considerable number of several months. The papules develop cases showing destructive naso-pharyn- into granuloma, sometimes isolated and geal lesions and also those which have sometimes covering the body, and this had as one of the symptomatic factors stage may gradually develop into the articular pains. tertiary ; indeed, in a certain number of I have seldom seen any reactions af- cases there will be no tertiary stage as ter the injection of neosalvarsan. A we believe the disease to be self-limited, few patients have had a slight chill, Castellani reports tertiary lesions as lasting for a few minutes, but they de- "gummatous nodules and deep ulcera- part feeling perfectly well, t^ons. ' One patient developed nervous symp- Pickett, reporting on his work done toms and a few moments after the in- m the Philippines, found three varieties jection began to toss about and com- of tertiary manifestations : "First, a plained of fever and of areas of itching somewhat persistent rheumatoid affec- over the body. Within five minutes he tion of certain joints; second, a local- developed large wheals, some of which ized ostitis or periostitis usually of one became the size of the end of the thumb, or more phalanges or near the wrist- The nervousness speedily subsided, in joint, and third, and by far the most an hour the wheals began to disappear common, a thickening and hardening of and were entirely gone in three hours, palmar and plantar surfaces with a de- No further difficulty arose in this case, cided tendency to cracking and soreness i had one interesting case which is during the rainy season." worthy of report. During the granu- Pickett reported that in his opinion lomatous stage a woman came to the salvarsan "is an absolute specific." He clinic with extreme photophobia, pro- found that oftentimes within six hours fuse lachrymation and iritis. The pho- after the injection of this drug, or one tophobia was so severe that it was with of the others which he used with good difficulty I could ooen the lids for the results, caused the yellow crusts of the purpose of examining the eye ; tears granulomata to dry up and darken and were continually dropping from both to disappear within a few days. The eyes. I was in doubt as to whether or lesions would gradually fade away, leav- not yaws was the causative agent of February, 1922. ORIGINAL COMMUNICATIONS 73 the ocular difficulty. On account of this doubt, I gave her an injection of neo- salvarsan and was surprised at the ra- pidity with which all the ocular symp- toms disappeared. Her frambesial le- sions were not as typical or as numer- ous as in ordinary cases but she made a complete recovery both as to the ocu- lar symptoms as well as the granulo- matous lesions. A recent report advises me that she is perfectly well. My great difficulty is in getting a sufficient supply of neosalvarsan. If we had a room in a hospital devoted entirely to neosalvarsan, we would have no trouble in keeping it filled, as pa- tients come on foot from 200 to 250 miles for treatment. There is such a demand and it takes so long to get neo- salvarsan here that sometimes we have to disappoint these patients. At this time I feel that neosalvarsan and the other arsenicals are a sure spe- cific for yaws. I am watching these cases very carefully and hope within three or four years to give a more defi- nite report of the results of treatment, as I will have more opportunity to travel among the people whom I have treated and get more satisfactory reports of the results. Another condition which I see many examples of is elephantiasis, a disease first observed in India about the Ninth Century, and, which Bancroft discover- ed in 1877, was transmitted by the mos- quito. The disease is a tropical or semi- tropical disease and its explanation can be found in these conditions found in the tropics, (1) where the mosquitoes can find moisture and temperature fa- vorable for breeding purposes ; (2) high temperature and much humidity in its bearing upon the patient, in that the transferred filaria from the mosquito would find it difficult to exist and work his way into the cuticle, were it not moist with perspiration and soft. For treatment may I suggest what I published in the Medical Bulletin a few years ago and which holds today. For the microfilariae in the blood I would suggest a trial of weak solution of bichlorid injected intravenously . So- dium cacodylate should be tried. Also tannic acid and salicylate of mercury. For the tumor operation, the technic which I prefer is one which I have not seen described. After marking off where you wish to amputate a scrotal tumor, leaving enough skin on the sides to cover the testicles (if possible) I be- gin to amputate from above downward. The cord, when reached, is easily fol- lowed to the testicles, which is anchored to the lower part of the tumor and the testicles freed. The penis is dissected out from the inside and the whole tu- mor then quickly severed. This saves the necessity of other incisions over the testicles and penis and consequent loss of blood. At least 50 hemostats are needed, and you may have to ligate 40 to 50 blood vessels. Usual closure of wound is made with interrupted sutures. Frequently quite a good deal of sloughing of su- perficial tissues results, but finally heals ^vell. The penis heals by granulation, com- plete healing is from six to ten weeks. ERRORS OF REFRACTION- ETIOLOGY AND TREATMENT By Dr. 0. J. Houser, Charlotte, N. C. The pathological errors of refraction are hyoeropia, myopia, astigmatism, and muscle embalancement. The natural or senile error is pres- byopia. First, hyperopia or far-sightedness is a condition in which there is a defor- mity. The eye-ball being so short in its visual axis that parallel rays are brought to a focus behind the retina. Myopia is a condition where the ball is too long in its visual axis, and the parallel rays focus in front of the re- tina. Astigmatism is a condition where different meridians have different re- fractive powers. The terms given to muscle embal- ancement are esophoria (the eye being turned in towards the nose). Exophoria (the eye turned out), hypophoria (the eye turned down), hyperphoria (the eye turned up). 'The only physiological defect which is brought about by nature is presby- opia; that occurs about the age of 40. This is caused by an atrophy of the lens which diminishes the refractive power. Examination: Under this heading does not conclude with the dark room test, the ophthalmometer, peremiter, and trial lenses. 74 SOUTHERN MEDICINE AND SURGERY February, 1922. There are many other pathological It is better to begin when the child conditions which might attribute to eye is five or six years old or even younger, weaknesses, such as tonsils, adenoids. Most family physicians in the past ad- bad teeth, sinus infections, brain tumor, vised the parents that the child may and many systemic conditions. out grow the defect, which has caused Many times diabetes, kidney lesions, a great deal of delay in those cases, and hemorrhage of the retina, or syphilitic converted each of them into a surgical conditions show up in the dark room case. It is by no means the ablest re- test before the general symptoms be- fractionist who gets the best results come alarming to the practitioner. with glasses. There is a great deal to Errors of refraction in most cases are be said about the optometry end of cor- present at birth and usually show up recting errors of refraction. The writer at school age. However, there are many has experienced the shop work which cases of latent defects which do not consists of lens grinding, frame making give trouble until later in life. This is and fitting, which plays a big part in due to the fact that the muscles of ac- carrying out the correction of refrac- commodation are sufficient to overcome five errors, the defect. After the lenses have been properly The symptoms accompanying these fitted, the next important thing is the defects are headache, and the patient centering of the lens, size, shape, etc. will complain mostly after a strenuous if a patient is wearing a lens with day's work or after looking at moving much power, and that lens is too small, pictures or takmg long automobile rides, so that the vision goes through the lens These symptoms are more noticeable at a part of the time, and over, or around bed time. The patient will complain of it a part of the time, this produces a severe pam at the back of the eye balls, rapid change of action of the muscles, These defects must be fitted with which causes headache, glasses under a mydriatic as the ac- jf ^ pair of (say 10 D spherical lenses commodation is so great that even the ^re fitted and decentered as much as 2 lens of correction will show up the test ^,, 3 m/M the patient is receiving a type dim and often mislead the oculist, prismatic power of about one degree. One of the most troublesome ques- , , , r.,.. , T., ,, tions we have to deal with is the con- , .^" ^J^^^'^ ^^ ^"^"^ ^^"-"f ^i^^ ^¥^ comitant squint: trial frame, or phoro-optometer, if Shall we operate or fit glasses? Both ^^^^^ "^^^^^ T ^J ,t J"'^^? I \l ^ operative and glasses are the treatment. ^/^ from the tips of the eye lash then In most cases glasses will have to be ^^!" S^ ?!^^^^| f/^ "^^^f ^9 ^^i ^^^^^^Z worn even after the operation. On bor- ?P ^^ tlie tips of the eye lash, the read- der line cases it is difficult to say just ^"?, T "^^^ ?""''-^ ^^^^.f ^"^f-^' 7'^''^^. which is best to advise the patient, "^^^l^^ displeasing to the patient, and operative or glasses same time not a full correction. If the patient is young it is certainly P^-^ blindness is another defect we have worth while to use the non-operative ^^,l^f "^^^t T /i. ^^ "^t an error of treatment, as the operation can be done refraction, but the patient will often later, and should be deferred until about ^^^^ ^^^''^' ^°^ ^^^^^^• puberty at any rate. ^ condition of which the sight is bet- It is obvious that where success can ^^^ ^^ dusk or in feeble illumination be obtained by non-operative means, than in bright light. This symptom is that should be the method of choice. found in toxic ambylopia, and with cen- The non-surgical treatment consists tral scotoma in general, in cases in of wearing glasses to correct any error „,u,-„i, i-x. 4. , •- • ... of refraction, periodic instillation of f^^^^ ^^^^^ ^''^ ^^"^^^^^ opacities of the atropin in the better eye, occlusion, etc. ^^"^ ^^ cornea. Prisms should not be used on every The patient sees better in reduced il- eye that does not show perfect test lumination, because the dialated pupils with the maddock rod, lest the eye will permit vision through the peripheral become a slave to them. , , . ^ .^ i , All cases of squint should receive ''^^^'^ P°''^'°" °^ ^^^ ^°™^^ ^"^ ^^"^• treatment before the age of puberty, as ^ P^^^ °f glasses with some shade the non-surgical treatment after that incorporated in the lens will give the age is practically a failure. best results we have to offer. February, 1922. ORIGINAL COMMUNICATIONS 75 THE MECHANISM AND MANAGE- MENT OF THE THIRD STAGE OF LABOR* Ivan Procter, M.D. Obstetrician to Mary Elizabeth Hospital, Raleigh, N. C. The purpose of this paper is not to publish any original ideas or theories but to present for your consideration certain important questions in the man- agement of the third stage of labor; questions that often confront those who practice obstetrics and at times those who practice gynecology and surgery. Upon the correct solution of these prob- lems depends the rationale of some of the newer methods of treatment. Our text books and the older writers hold to the theory that separation of the placenta is due to reduction in the area at the placental site. Hirst' says the most probable explanation of pla- cental separation is found in the theory of diminution in the area of the pla- cental site, which the placenta follows to a certain point when, becoming solid by the approximation of villi and the obliteration of the lacunae, it no longer follows the contraction and retraction of the uterus and is sprung off from the uterine wall. It requires several pains to accomplish this so the placenta is not detached for 15 to 30 minutes after the birth of the child. Frankr argues against the most com- monly accepted theories of detachment. First, disproportion between the mate- ral side of the placenta and the area of attachment ; second, formation of the retro-placental hematoma; third, direct expulsion of the placenta as a foreign body by uterine contractions. He uses the X-ray studies of Weibel and Warne- kros as a basis for his argument. The placenta is completely separated imme- diately after the expulsion of the fetus. The area of placental attachment is thinner than the uterine wall at the same level, and this thinned area does not participate in a uterine contraction as long as the placenta is attached. This fact is confirmed by observations at Cesarian Section. From histological study Frankl concludes that loosening *Read before the Sixth District Medical So- ciety at Raleigh, N. C, June 30, 1921. is affected by the escaping blood due to a rupture of the over distended blood vessels in the Spongiosa Septa. The blood vessels rupture when an excessive amount of blood suddenly flows into the uterine wall as soon as the fetus is ex- pelled. Heiss' agrees with Frankl's view of the mechanism. Franz' explains the mechanism of de- tachment as follows : The intra placen- tal pressure is raised; the placenta is felt to enlarge and harden and thus the relation to the now relatively smaller area of attachment is altered. When- ever the detachment at first is only par- tial, this increase in size and tention is absent, the normal mechanism is inter- fered with and several contractions are necessary for completion of the separa- tion. Failure to ligate the placental end of the cord causes delay in the loosen- ing of the placenta from the uterine wall by partial emptying of the placen- tal blood. Moeller disagrees with Franz and bases his conclusions on observa- tions in 1,300 cases in which the pla- cental end of the cord was not ligated and the partial emptying of the placen- tal blood favored expulsion of the smal- ler placenta. Franz states that as a rule the entire maternal surface of the placenta is detached at the same time by but one uterine contraction. When- ever the body and lower extremities are expelled by a contraction the placenta immediately afterwards is found com- pletely loosened. If the second stage ends without a contraction, one more contraction is necessary. Franz bases his conclusion on manual exploration of the uterine cavity in 96 cases, under rigid aseptic precautions immediately after the expulsion of the fetus. So summarize : There are two schools. One believes the placenta is separated immediately following the birth of the child, and they base their conclusions upon rational observations. The other school believes several uterine contrac- tions are required to separate the pla- centa, and this is not accomplished for at least 15 to 30 minutes after the ex- pulsion of the fetus. This school has the clinical fact that the placenta is not often located in the lower uterine seg- ment for 15 to 20 minutes after the birth of the child. The question has been raised — why be concerned over the time of separation ? The answer is sim- ple, for upon this fact depends the man- agement of the third stage of labor. If 76 SOUTHERN MEDICINE AND SURGERY February, 1922. the placenta is normally separated im- mediately after the birth of the child then gentle manipulation or massage of the uterus will lessen the hemorrhage. But if the separation does not take place for some time and there is only partial detachment, this same manipu- lation will increase the hemorrhage. Hence the management of the third stage of labor depends largely upon the time of separation and not upon how it separates. John Osborn Polak' in a study of the placental stage in 2,000 consecutive de- liveries at the Long Island College Hos- pital drew the following conclusions: 1. That the placenta will separate spontaneously if the normal mechanism is not disturbed. 2. That any manipulation before the clinial evidences of separation are ap- parent, disturbs the normal mechan- ism. 3. That post partum hemorrhage is best guarded against by the observance of the physiological processes and that partial detachment the result of manip- ulation predisposes to bleeding. 4. That sepsis is dependent upon pen- etration of the uterus by hand or in- strument through infected passages. 5. That manual extraction is only ad- missable in partial separation with hemorrhage. 6. That in retention of the placenta without hemorrhage the cord should be cut off close to the cervix and the case watched until signs of separation are apparent, when the placenta may be ex- pressed by Crede's method while the patient is under surgical anesthesia. 7. When the adhesion is so great that its removal entails the digging of the placenta out piece meal, excision of the placental site or hysterectomy should be the choice made. If we accept the theory of the second and the older school that the placenta does not separate for 15 to 30 minutes after the birth of the child, then the least uterine massage or manipulation is the best treatment. I have found it not even necessary to keep the hand on the fundus for the body of the uterus to stay in its physiological state of to- nicity. I believe that with the hand on the fundus the normal amount of bleed- ing is often taken to be excessive and the ever present hand instead of admin- istering gentle massage, uses anything from light continuous pressure to force- ful bruising of the uterus. Such treat- ment interferes with the normal mech- anism. More erroneous than these practices is the supposed necessity for Crede treatment in the conduct of every third stage of labor. I dare say that at least 90 per cent of medical students and internes are obscessed with the idea that to terminate successfully the third stage of labor when the placenta is not spontaneouslv expelled following the birth of the child, or within 20 or 30 minutes thereafter, the treatment par excellence is Crede with enough pres- sure to produce expulsion. Hart of Edinburgh believes that one of the most probable causes of persistence of puerperal sepsis since pre-antiseptic days is the use of the Crede method of expressing the placenta. When this method is used early or late there is great danger that small pieces of pla- centa or membranes may be left. He confirms this statement by post mortem examinations and asserts that supra pubic pressure in the line of the axis of the pelvic canal, using the uterus as the piston of a syringe, will produce the same results without the ill effects. The statement (Polak) that it does no harm to leave small bits of membranes in cases that have been conducted aseptically is a dangerous one and should not be accepted. Regretful as it may be our obstetrical asepsis is only relative and not absolute. When we leave dead material in the uterus we leave fertile soil for the growth of bac- teria. Crede reported that the average time of expulsion in his 2,000 cases at Leipzig was 41/0 minutes. In the same report he says that in 18 cases the en- tire chorion was retained and in the 78 parts of it. Here I will call attenton to the distinction between separation and expulsion — terms that are often mis- leading but more often misinterpreted. Separation should not be hastened by pressure on the fundus, for if the physiological rise of the uterus is pre- vented, the detached placenta may pass so quickly down the lower uterine seg- ment or vagina that the membranes still partially adherent may be torn from the placenta. Hart gives the pla- centa one hour to separate if there is no excessive bleeding, stating that the placenta and membranes separate first in discreet areas and if expression is February, 1922. ORIGINAL COMMUNICATIONS 77 used early it often results in tearing off of the separated from the unseparated parts. ' ' The separated placenta is recognized: First, by the cord becom- ing limp and advancing 5 to 10 cm. ; second, by elevation of the fundus ; third, by anterior-posterior flattening of the corpus uteri ; fourth, by a gush of blood from the vagina which ceases as the uterus retracts; fifth, finally by the appearance of a soft boggy mass (pla- centa) just above the symphysis. Once the placenta i.s separated and in the lower uterine segment it should be re- moved. Experience having taught us that the expectant treatment offers nothing and invites disaster. The so-called practice of "Kneading the uterus," "Steadying the fundus," "Holding the fundus," or gentle ma.s- sage in the absence of hemorrhage is entirely uncalled for. The" state of inertia (5 to 15 min- utes) following immediately after de- livery is physiological and should not be interfered with by any form of mas- sage or manipulation. 'As Gibson of Chicago aptly puts it: "There should be a good clinical picture of detached placenta before Crede ex- pression is attempted. And if attempt- ed prematurely there is grave danger of a real alternation in the delicate mechanism of separation which in its turn brings us to a possible manual in- vasion of the uterus with its estimated mortality of 5 to 10 per cent. Dr. Gib- son wrote me a few days ago that at St. Luke's Hospital, Chicago, there has been exceedingly little difficulty with the third stage since they stopped all massage and manipulation until after positive separation of the placenta. Last September I had the opportunity to be with Potter of Buffalo for a week. Potter says his success with the third stage of labor comes from leaving it alone. (Very different from the way he treats the second stage!) He be- lieves massage delays separation and is sure that Crede treatment should not be used until after complete detach- ment. Potter and Gibson both give pituitrin hypodermatically at the close of the second stage and the result is a shorter placental stage with less hem- orrhage. Before expression is attempt- ed the bladder should be emptied, and the uterus contracting in the mid line. Baer'" assists expulsion of the detached placenta by grasping the recti between the fingers and thumbs of the right and left hands above the umbilicus. Hold- ing the recti close together and having the patient bear down, the muscles act more effectively, the uterus is driven downward and the placenta expelled. In the last few years there has been described by several writers a new and artificial method of hastening separa- tion. The principle involved was first described in 1826 by Mojon, professor of Anatomy at Genoa, Italy. The tech- nique used by Sklavonos" is to cut the cord near the vulva, insert a cannula in the umbilical vein, tie in place and inject 200-250 c.c. sterile saline contain- ing 2 per cent citrate. The salt sol, tends to prize off the placenta by in- creasing its weight, acting as a wedge, and as a direct stimulus to the muscle libers. In a few minutes the patient ex- periences a burning sensation with pain. Watery blood flows from the vagina. The fundus rises and the cord slips out four or five inches, which phenomena indicate separation. The placenta now lies in the lower uterine segment or the vagina until expelled by a strong pain or supra pubic pressure. The points in favor of this method are : First, it has been successful in cases in which mas- sage and Crede treatment failed. It causes less trauma to a most vital or- gan. It gives tone to the uterus in- stead of injuring it. It stimulates firm, complete, and regular contractions of the uterine muscle. The third stage of labor should be just as distinct a physiological entity as the second. The same general prin- ciple of management should apply. That is, the accoucheur should study the mechanism as it develops under his vig- ilant eye and interfere only for good reason. Of course, it is no more possi- ble to govern the third stage of labor by a fixed rule than it is the second. At the close of each third stage there should be a careful, painstaking and de- tailed examination of the placenta and membranes. The entire third stage Sjhould be executed with redoubled care as to asepsis. A fresh sterile pair of gloves should be used for this most im- portant stage of labor so fruitful with clanger and ill results. ""More women cjie from accidents of the third stage than from the first and second stages combined." The Parturient woman's freedom from post partum hemorrhage, complete expulsion of the secundines, 78 SOUTHERN MEDICINE AND SURGERY February, 1922. smooth convalescence and even her health in later life depends upon proper conduct of third stage of labor. Conclusions The true mechanism of placental sep- aration remains unsolved. The placenta normally separates in 15 minutes to two hours after birth of the child, usually within 20 to 30 min- utes. Any kneading, holding, massag- ing or manipulating the uterus before clinical evidence of separation disturbs the normal mechanism and should not be used. The use of pituitrin at the end of the second stage probably elimi- nates many "so-called" indications for massaging the uterus. Disturbances in the normal mechan- ism predispose to hemorrhage and re- tained secundines. The injection meth- od and expectant treatment should be tried before manual invasion, in the absence of hemorrhage. The advantage of single ligation of the cord over double is undecided. Crede treatment probably has a very limited field in normal obstetrics. The best results are obtained by pi- tuitrin, the absence of massage and manipulation, and supra pubic pressure after complete detachment of the pla- centa. If in preparing the paper on the third stage I have seemed to dwell excessively upon the subject of uterine manipula- tion, it is because I believe it to be of vital importance. We have followed too long the path of our forefathers without looking to the right or left or without satisfying ourselves that their path was the correct one. Let us think for our- selves, each man go to work on this third stage problem and help lessen the morbidity and mortality of childbirth. References 1. Hirst: Text of Obstetrics, 200. 2. Frankl: Monatsschrist fuer Geburtsilfe Und Gynaekologie, 1918, XLVII, 217. 3. Heiss: Weiner Klinische Wochenschrft, 1920, XXXIII. 4-8. Frang: Monatsschrist feur Geburtshilfe Und Gynaekologie, 1919, I, p. 184. 5. Moeller: Gynaekologische Runduschau, 1913, VII, 339. 6-9. J. 0. Polak: Gynec. Transactions, Vol. 40, 100-110, 1915. 7. D. B. Hart, Edinburgh Medical Journal, April, 1920. 10. J. L. Baer: J. A. M. A., Vol. 76, page 566, Feb. 26, 1921. DOCTORS AND DREAMS (New York Times, Sept. 12, 1921) A significant and important point in the history of science is marked by the formal recognition by the British Medi- cal Association, at its recent annual convention in Newcastle, of psychoan- alytic and psychotherapeutic methods as legitimate and effective in the treat- ment of certain mental and nervous dis- eases. This action deserves attention, not because all the doctors of England and other countries, including the United States, hitherto have refused to counte- nance these methods, and have ignored or condemned Freud and all his works, but because it gives a certain regularity or warrant of high medical authority which psychoanalysis up to this time has lacked. Here and elsewhere the reputable medical journals long since stopped the constant ridiculing and denouncing of the Viennese phychologist and began to take him and his theories seriously. They are printing innumerable articles on the subject, some by doctors who doubt or deny his soundness, but of late these journals have contained many more articles whose authors have learn- ed in daily practice the utility of the new device for the exploration of the human mind and that "readjustment to environment" which is its aim. Its an- tagonists are not yet all dead by any means, but they obviously are carrying on a losing fight — one that in reality was lost some time ago. As was to be expected from such a body, the British Medical Association, in making the announcement of its ap- proval, emphasized the fact that psychoanalysis is a worse than worth- less, a dangerous, tool in other than skilled hands, and that the only right preparation for its use is a thorough medical education. It is a field into which too many charlatans have en- tered, some of them vicious, the others merely ignorant, and it is hard to tell which of the two classes is doing the more harm and the more to bring into disrepute discoveries that potentially are of almost incalulable value. February, 1922. EDITORIAL Published Monthly by the Charlotte Medical Journal Company M. L TOWNSEND, M. D. \ J. C. MONTGOinERY, M. D. Editors CHARLOTTE N, SOUTHERN MEDICINE AND SURGERY ™aS,es^,;;"chSTo1 ll!.Z:7k many compounds, including sodium iodid, which composes the remaining 11.3 per cent. It has an average total salinity of 3.4404 per cent. All of the salts in sea water are unusually soluble in plain water. The great solubility of sodium iodid accounts for its almost complete absence from the land surface "Read not to contradict and confute, nor to and, perhaps, for some of the peculiari- !,•.„„ „„^ .„,,„ * .„^ „__ ._ «_. ..n- ^jgg j^^^g^ j^ YegBiYA to the incidence of goiter. Authorities are agreed that goiter is infrequent in both animals and man along the sea. The same is true, also, of some fishes (salmons) which inhabit both fresh water and sea water, tending to develop goiters in the for- mer, and none in the latter. Appar- ently, sea animals do not have goiter. Practically all salt used in the United States for dietary consumption is ob- tained from inland sources by the evap- oration of brines, which for the most part are inherently free of iodin. Ir- respective of the source, whether sea water or inland deposits, the modern processes of preparing the purified salt free it from all traces of iodin, as well as its other naturally associated elements, many of which are identical with the body fluids of higher animals. believe and take for granted, nor to find talk and discourse, but to weigh and consider." — Francis Bacon. Iodin and Goiter, Recently a physician of broad experi- ence and an unusually keen student throughout many years of practice, commented that he had empirically giv- en adolescents ; especially girls, some preparation of iodin, more often the or- dinary tincture of iodin in 3 to 5 drjp doses daily, although not continuously, over a period of one to five years, or until after the menstrual cycle was firmly established, and that in not one case of the scores and perhaps hundreds who had followed this procedure had he seen develop any signs of exophthalmos Ha^huV-st^omtrout^raroYrhe'depen^^^^ or goiter. able sources of iodin in nature — sea air, sea food and sea water — it is to sea wa- ter, used perhaps in place of common salt as a condiment, that inland dwell- ers should look. This substitution would appear to offer a complete solution to the iodin deficiency problem, if nothing else, while evidence would tend to show that other constituents of sea water have also an undoubted place in the economy of the higher animal organism, perhaps to the extent of precluding This hint from a source we could not question made us especially interested in an article by Dr. Emery R. Hayhurst, Columbus, Ohio, which was published in the Jan. 7, 1922, issue of the J. A. M. A., entitled, "Present-day Sources of Common Salt in Relation to Health," Dr. Hayhurst comments on the natural deficiency of iodin in diets ; yet its scarc- ity in nature has been long known to geochemists, as well as its infrequency of occurrence in salt sources by commer- cial and industrial chemists. While ^^^^ diseases which are likewise, pos- iodin may occur in natural deposits sibly, of a deficiency type. Common salt along with chlorin, usually in the form for dietary purposes should include not of the sodium salt, it is never obtained only sodium chlorid but also sodium from such sources commercially because iodid, and undoubtedly many of its it occurs in too limited quantities. Chili other original concomitants. For geo- saltpeter is the chief source of iodin. chemical reasons, great care should be The sea is the great storehouse of iodin taken in selecting its source, if it is not where it completes a cycle from inor- actually derived always from sea wa- ganic compounds to organic life and re- ter. It must then be handled commer- turn. The salts of sea water are con- cially in a manner to retain these con- stant in both quality and quantity. So- stituents. 80 SOUTHERN MEDICINE AND SURGERY February, 1922. How Physicians Die. Careful estimates have shown that in 1921 the total number of deaths of phy- sicians in the United States and Can- ada was 2,343 and the estimated total number of physicians 160,000. This is equivalent to an annual death rate of 14.65 per thousand and the average an- nual mortality rate of physicians from the period of 1902 to 1921, inclusive, is 15.05. Of this total number there were 2,118 whose age was stated and of these 29 were under 30; 160 between 31 and 40 ; 298 between 41 and 50 ; 409 between 51 and 60 ; 571 between 61 and 70 ; 393 between 71 and 80 ; 240 between 81 and 90; 17 between 91 and 100, and one lived to the age of 101. Sixty-six is the age given for the greatest number of deaths. Doctors may be hard worked and very irregular in their habits of living, however, longevity does not look so bad after all. In the case of 2,009 of these deaths the cause is recorded and shows more than one-fifth (or 426) of them to be the result of diseases of the heart and circulatory system with an additional 196 from cerebral hemorrhage, while general diseases account for 290 sub- divided as follows : Carcinoma and sar- coma, 128; tuberculosis, 47; septicemia, 29; diabetes, 24; typhoid fever, 15; anemia, 14 ; diphtheria, 8 ; and other in- fectious diseases, 25. Of the other causes there were paresis, 37; menin- gitis, 18; neuritis, 14; epidemic encap- halitis, 11 ; and other diseases of the nervous system, 8. Pneumonia, 167; influenza, 19 ; bronchitis, 11 ; and other diseases of the respiratory system, 11. Appendicitis, 32; cirrhosis of the liver, 19; gallstones, 17; strangulated hernia, 13; peritonitis, 12; and other diseases of the digestive system, 79. Chronic nephritis, 79; acute nephritis, 26; ure- mia, 23 ; and other diseases of the gen- ito-urinary system, 18. Various diseases of the bones, 9; diseases of the skin, 3; senility, 213; sequels to operations, 91 ; complication not specified, 38 ; acci- dental and homicide, 97 ; suicide, 69. The accidental deaths are further sub-divided into automobile- railway (grade crossing), 22; automobile, 19; firearms, 17; railroad and street cars, 14; poison, burns and fractured skulls, 16 ; electrocuted while treating patient with roentgen ray, 1 ; homicides, 19. Automobile Fatalities. Within the registration area of the United States it is reported by the Bu- reau of the Census there were in 1915, 3,571 deaths as a result of accidents caused by automobiles and motor vehi- cles, excluding motorcycles. This repre- sents a death rate of 5.8 per 100,000 population. The records show a gradually increas- ed number of deaths from this same cause each year until in 1920 there were 9,103 deaths or a death rate of 10.4 per 100,000 population. This increase is as follows: 1915, 5.8; 1916, 7.3; 1917, 8.9; 1918, 9.1; 1919, 9.4; 1920, 10.4. In the registration area including 25 States it is curious to note that the State with the lowest mortality is Vir- inia, showing in 1920 a death rate, from motor vehicles, of 4.2 per 100,000, with a total of 97 deaths. North Carolina shows a death rate of 5.2 with a total of 133, South Carolina showing 5.4 with a total of 91. While New York State shows a death rate of 13.5 with a total of 1,410, also the State of Washington shows a death rate of 13.5 with a total of 184. These figures express proportions in- dicating that some common factor in these three States works to produce the lowest death rates in the United States from accidents which we frequently term carelessness. Does it mean that the people of Virginia and the Carolinas are less careless in their driving and in the observations of traffic regulations? We might say that the dense population of New York State made the rate higher there, but, can we say that this would be the cause for the high death rate in the State of Washington. We want to believe that there is a sectional characteristic in these three sister States manifesting itself in care- fulness in the discharge of all daily transactions as well as in driving auto- mobiles. We want to believe that this same inherent characteristic makes the doctors of the Tri-State Medical Asso- ciation of the Carolinas and Virginia above the average in painstaking thor- oughness and in the efficient discharge of their duty pertaining to the practice ot medicine. Taking chances on slippery pave- 'nents, in reckless driving, in "shooting a hole" in traffic often results disas- trously. Taking reckless chances with February, 1922. EDITORIAL tl human life has often resulted disas- typhoid infection should always be con- trously. sidered and if improvement does not May we let this be an encouragement follow the use of the combined vaccine, to us to ever be more and more care- a typhoid vaccine should be employed ful about "reckless driving" in the prac- and the case regarded as typhoid car- tice of medicine. rier until otherwise ascertained. Where gallstones are present they „ , , , ,. . mi- • should be removed surgically and tak- Polyvalent \ accine-Therapy in j^g cultures from scrappings of the gall Cholecystitis. bladder should not be neglected. Re- Cholecystitis is now known to be due moving an infected gall bladder or to infection. It was once supposed that drammg the same after removmg the gallstones were the cause of gall blad- gallstones is always associated with der irritation and inflammation but some danger of postoperative extension from careful investigation it has been of the mfection. For this reason it is a found that gallstones are a by-product good practice to give the patient im- of inflammatory processes due to infec- munizing treatment for several weeks tion. From this it is evident that in- Pi'ior to the operation; and after the fection of the gall bladder exists long operation the same combined vaccine before gallstones develop. Streptococci should be employed to hasten a com- and colon bacilli are the most common Plete recovery. If unusual organisms organisms found with staphylococci and are found in the cultures taken, an au- pneumococci as the other principal in- togenous vaccine should be made and vaders. In some cases of cholecystitis employed. following typhoid fever, tvphoid bacilli may be responsible for the infection ^he Referendum on Alcohol. Drug treatment of these cases is at best unsatisfactory and from the pathologi- In hearings before Congress, in the cal condition found this should be ex- discussion of regulations issued by the pected. It is well known that drugs Internal Revenue Department, in fact, possess no direct immunizing proper- in practically every discussion of pro- ties, so when an infection develops in hibition, contradictory statements have an inaccessible part of the body where been made as to the views of physicians local treatment is irnpossible, drug on the value of alcoholic beverages as treatment becomes problematical. In- therapeutic agents. Several scientific fections of the gall bladder, like infec- organizations have adopted resolutions tions of other parts of the body, will on the subject. So far as we know, subside in many cases by immune de- however, no attempt has heretofore velopment as a result of the infection, been made to ascertain, in a direct way, Unfortunately, such immune develop- the opinions of any considerable num- ment is often too tardy and meantime ber of physicians. gallstones develop. Active immuniza- Moreover, the medical profession has tion with the aid of bacterial vaccines, been subjected to ridicule and criticism however, offers a distinct therapeutic on account of the actions of a small aid in the treatment of these cases. number of its members who are abus- If treatment is started before gall- ing their privileges and who have as- stones have developed complete recov- sumed a position in the public eye not ery is to be expected. A combined colon creditable to the profession as a whole, bacillus, streptococcus, pneumococcus. It therefore seemed worth while to ob- and staphylococcus vaccine should be tain the views of a large number of employed. The infection being essen- physicians regarding the effect on med- tially sub-acute or chronic, treatment ical practice of the present regulations ; should be started by giving the usual to discover whether or not conditions small dose of 0.2 mil. and then grad- might be improved, and if so, how. ually increasing the dose to 1.0 mil.. In order to secure the views of a rep- making inoculations at about five-day resentative portion of the medical pro- intervals. Improvement may be confi- fession a questionnaire was sent to more dently expected soon after this vaccine than one-third — 53,900 — of the physi- treatment is instituted. cians of the United States. Of these, Where the cholecystitis dates from 43,900 were selected by arbitrarily tak- an attack of typhoid fever, a possible ing every other name on the mailing 82 SOUTHERN MEDICINE AND SURGERY February, 1922. list of The Journal. In towns in which there was only one physician, the ques- tionnaire was sent to that physician. In addition, the questionnaire was sent to 10,000 physicians who were neither members of the organization nor sub- scribers to The Journal, These names were selected in a similar manner, but from the medical directory. The excellent response, reaching 58 per cent of replies and representing 21.5 per cent of the physicians of the country, a percentage of return seldom attained by the questionnaire method, has been gratifying as an indication of the interest taken by our profession in this attempt to secure an adequate ex- pression of its views. As might have been expected. The Journal has been accused by many of preparing these questions wholly in the interest of prohibition, and an equal number have asserted just as emphat- ically that the questions were intended as the opening wedge for breaking down prohibition. Some have taken exception to the word "necessary," claiming that no drugs are absolutely necessary, and that "desirable" or "advisable" would have been a better word for the purpose. This point was given careful considera- tion in formulating the question. More- over, the word "necessary" is used in the National Prohibition Act itself (Sec- tion 7, Title II) :" . . . And no physician shall pre- scribe liquor unless after careful phy- sical examination of the person for whose use such prescription is sought, or if such examination is found imprac- ticable, then upon the best information obtainable, he in good faith believes that the use of such liquor as a medicine by such person is necessary and will afford relief to him for some known ailment. The word "advisable" or "desirable" would have been as much too mild as "necessary" is, perhaps, too strong; "necessary" does not mean indispensa- ble, and it was properly regarded by practically all who answered the ques- tionnaire. have been published in connection with reports on the individual states. Many of the views brought out in the com- ments are of value to those who are interested in the subject from the so- ciological or from any other point of view. For instance: Since national prohibition went into effect, judging by these comments there has apparently been a reaction against prohibition in many states in which prohibition by state law had become accepted and ef- fective. This is especially noticeable in the comments from Colorado, Kansas, Nebraska, South Dakota, and even from Maine. From the comments, one must come to the conclusion that home-made, illegally distilled or chemically com- pounded liquors — so-called "moonshine" — are being extensively used in states in which this was not the case three or four years ago. What has produced this apparent change? The questionnaire has brought out definitely the fact that the present reg- ulations governing the medicinal use of alcoholic beverages are not satisfactory — in fact, many physicians declared them "intolerable." Many who were convinced that these drugs were not necessary therapeutically were emphat- ic in stating that other physicians who believed them necessary were entitled to have their views respected, and were warranted in efforts to have the drugs made available without incurring the odium attaching under the present reg- ulations. Evidently most physicians are satis- fied with the control of narcotics as reg- ulated under the Harrison Narcotic Law, and many expressed a desire that the control of alcoholic liquors follow such lines. A decidedly large number of physicians suggest that t he govern- ment take over the whiskey, including its storage and sale, and supply it in sealed packages — say of 8, 16 and 32 ounces — for medicinal use only, and at a fixed price, under regulations similar to those of the Harrison Narcotic Law, thus making available to physicians a drug of dependable quality. — Jour. A. M. A., Jan. 21, 1922. Approximately one-third of those re- The next annual meeting of the Tri- plying commented on the general prohi- State Medical Association will be held bition situation, on the restrictions and February 22-23, 1922, at Norfolk, Va., regulations, or on some allied topics, with headquarters at the Montieello The more interesting of these comments Hotel. February, 1922. EDITORIAL 83 G3mecology and Obstetrics Robert E. Seibels, M. D., Dept. Editor Ovary and Endocrinologist. The development of the female (Mai- ler's) duct system from an indifferent anlage is dependent on the presence of the ovary. The transformation of the infantile genital tract, inclusive of the secondary sex characters, to the adult stage results from a quantitative in- crease in ovarian secretion. The normal sexual cycle includes maturation of an ovarian follicle, ovulation, impregna- tion and pregnancy. Menstruation sig- nifies the abortion of an unimpregnated ovum. The accompanying uterine changes are in many ways analogous to those occurring in abortion. Decrease or increase in ovarian secretion can pro- duce clinical manifestations. Similar manifestations may result from other (non-ovarian) causes. Robert T. Frank, Denver (Journal A. M. A., Jan. 21, 1922), claims that the ovarian extracts now in use have been deprived of the small amount of active substance that they have contained when fresh. Their pharmacologic effect on the sexual tract is nil. This does not imply that a po- tent extract cannot be elaborated. in the fight for correcting the present vicious habit of compression which re- sults in atrophy of the breast. It re- lieves pain in nursing mothers and dur- ing menstrual periods. It supports dur- ing the periods of pregnancy and lacta- tion and is an aid in the period of in- volution, preventing the pendulous con- dition so common after childbearing. It acts as a control of shoulder girdle po- sition and is an aid in the correction of spinal alinement. Heavy Breasts as a Factor in the Pro- duction of Faulty Posture. C. L. Lowman, Los Angeles (Journal A. M. A., Jan. 21, 1922), is of the opin- ion that neuritis and various forms of bursitis in the shoulder girdle region may be caused by heavy breasts. When the breasts are abnormally heavy and the tone of the back and shoulder mus- cles is lessened the weight of the breasts pulls the shoulders downward and for- ward, and by spreading the scapulae, stretches the rhomboid muscles, and of- ten produces irritation along the spinal column in the region of their insertion. To overcome this condition, Lowman has devised a special brassiere which controls excessive breast movement and supports and corrects pendulous breasts without producing atrophy. It also pro- tects from irritation and trauma against the top of the corset. It serves as a prophylactic aid to corrective clothing Urology A. J. Crowell, M. D., Dept. Editor Dr. Chas. S. Levy, of Baltimore, re- ports in the January Journal of Sur- gery, Gynecology and Obstetrics, page 22, a clinical analysis of 30 cases of "Essential Hematuria" with the follow- ing conclusions: 1. That the various theories which have been offered as explanations of hematuria are not satisfactory. The literature, he says, is full of theories as to its pathology but none of the kidneys removed for this condition have yielded constant findings. Some are reported as being normal ; others had small iso- lated areas of interstitial or glomerular nephritis; some chronic passive conges- tion due to obstructed urinary outflow or congestion secondary to heart le- sions. Two of Dr. Levy's cases were studied at the Brady Urological Institute and two from the gynecological service of the Johns Hopkins Hospital. The summary of his report is as fol- lows : 1. The diagnosis of essential hematu- ria should be made only when all known urological methods have been employed with negative findings. It is a purely clinical diagnosis, indicating renal bleed- ing of unknown etiology. 2. This paper comprises the studies of 30 cases diagnosed as essential hema- turia, based on clinical studies supple- mented by conclusions drawn from a questionnaire, the questions of which were so framed as to include the possi- bility of subsequent development of nephritis, urinary tuberculosis, calculi of urinary tract, renal tumor, operative procedure upon the kidney involved, and recurrences of hematuria. 84 SOUTHERN MEDICINE AND SURGERY February, 1922. 3. In 36 per cent of the cases the on- 13. From an analysis of the question- set of the hematuria occurred in the naires we can easily infer that none of fourth decade of life. the patients has developed nephritis, 4. The bleeding in essential hematu- renal or ureteral calculus, tuberculosis ria is for the most part symptomless. in any form, or renal tumor, and none 5. In most of the cases the hematuria has had an operation on the genito- developed spontaneously. Exertion does urinary tract. not appear to play a significant role in 14. Prognosis in essential hematuria the origin of these hematurias. is favorable in spite of the loss of blood 6. The right kidney was responsible and the recurrences of hematuria, for the bleeding in 17 cases and the left in 13 cases. In no case were both kid- Dr. E. Papin, Medecine, 3:63, Paris, neys involved. October, 1921, in a paper on "Examina- 7. The results of operative proce- tion of a Patient with Prostatic Hyper- dures have not been better than those trophy Before Prostatectomy," empha- of non-operative methods. In our series sizes the importance of rectal palpation there were recurrences after decapsu- of the prostate to determine its size and lation and two nephrotomies. Nephrec- consistency ; catheterization to deter- tomy is the only operation ever indi- mine the degree of urinary retention; cated, and that only as indicated as an cystoscopy, and if necessary radio- emergency measure to save a patient graphic examination of the bladder to from bleeding to death and not as a rou- determine the condition of the bladder tine measure for intermittent hematu- walls and mucosa, the presence of tu- ria over a long period. mors or diverticula of the bladder, cys- 8 The non-operative methods have titis, incrustations, or varices. To de- been used with success. These have con- termme the general condition of the pa- sisted of intrapelvic injection of silver tient the Wassermann test and func- nitrate and adrenalin, and of the pas- tional kidney tests should be made, the sage of a ureteral catheter; the oral ad- blood pressure recorded and a thorough ministration of calcium lactate and the examination made of the heart, lungs subcutaneous or intramuscular injection and gastro-intestinal tract. Such a of horse serum. Of these the intra- thorough study of the patient gives pelvic methods have been given the definite indications for prostatectomy, best results, and it is of interest to note Operation is contra-indicated in patients that in a large number of the cases of who are syphilitic or who have bladder the series the urine had become clear diverticula. Preliminary cystostomy within a week or ten days after this should be done on patients with marked form of treatment urinary retention, inflammation or cal- 9. It is suggested that the pelvis of ^^^^^^ the bladder, or atony of the the kidney be completely distended with etnt'/enr' uncul Tnd nit'rUf rete^^ fluid whenever intrapelvic injections are J 'f o^'^^ereased blood nressure Pr " employed. That distention is an im- "^^ ^^ increased blood pressure. Pri- portant factor in this therapy is shown ^f ^ T"" .t ki °^T ""^^ a ^°"f-,-^'' in many cases in which the hematuria P^Jlf^^s with bladder in good condition has ternporarily disappeared after the ^^^^out much retention, with good rena injection of an ouaque medium for pyel- ^""^^lon and normal or nearly normal ographic studies: b^^^ pressure. Obesity usually indi- 10 The 30 cases have been followed '^''' ^" unfavorable prognosis, from one month to 121/2 years. There q^^^^^ j^g^ egp^n ^e ^rol. y dermat, have been 12 cases with no recurrences 23:287, Madrid, May, 1921, in his paper, of the hematuria, and 18 cases with re- ..^he Therapeutics of Incomplete Pros- currences. Of the latter there are two ^^^j^ Retention with Distention of the whose urine is bloody at the time of Bladder," urges "that no prostate with writing. It is not safe to predict cures, chronic incomplete retention and disten- 11. Spontaneous cessation of the tion of the bladder should be treated by bleeding occurs frequently in essential catheterization. The formula of "grad- hematuria. ual progressive evacuation of the blad- 12. The general health is usually not der with general tonic medication" has affected by the loss of blood in essential never cured anybody. The ideal treat- hematuria. ment is to begin with cystotomy, fol- February, 1922. EDITORIAL 85 lowed with a diet of fruits and green I heartily agree with practically all vegetables, general massage, and res- the conclusions of these three men ex- piratory gymnastics, to increase the cept their plan of drainage and opera- general strength ; then to determine by tion. The indwelling catheter is better frequent urinalysis the most favorable than the cystostomy and the perineal time for radical operation. Local novo- operation far safer and better from cain anaesthesia should be used for cys- every standpoint than the suprapubic, tostomy ; for prostatectomy, a mixed Novocain infiltraton and gas anaes- narcosis of somnoform and chloroform, thesia are far better and safer than These are the bases on which rest re- chloroform for cystostomy if it becomes suits widely different from those of ear- necessary to resort to it. lier times. Cystostomy is much simpler than catheterization under difficult cir- cumstances. A Marion tube of medium size is inserted. The relief from pain causes rapid improvement in the gen Mental and Nervous James K. Hall, M. D., Dept. Editor eral condition and prepares the patient for prostatectomy. In patients of ad- vanced age, resection of the vas defer- Archives of Neurology and Psychia- entia is performed under local anaesthe- try for February, 1922, publishes a pa- sia at this time. In performing the la- per read by Dr. Pearce Bailey, of New ter prostatectomy, Oreja is insistent on York, before the American Neurologi- the tamponing of the cavity with com- cal Association at its last meeting in presses as a valuable precaution against f^^^"^^", ^,'% ''\^T\l^^h o^'I^f ' r , '^ A Contribution to the Mental Patholo- hemorrhage. g^, ^^ j^^^^^ i„ ^^^ U^i^^^ States." He assumes with Kraepelin that the Dr. W. C. Stirling, Virginia M. mental make-up of a people may be es- Month., 48:402, October, 1921, on "The timated with considerable accuracy by Importance of Early Recognition and a study of the type of mental abnormal- Treatment of Prostatic Hypertrophy," ity manifested by a geographic group concludes that palliative measures are or by a race. As the basis of his study useless. If the amount of residual urine he makes use of 69,394 cases of mental withdrawn per catheter is 60 c.c. or abnormality diagnosticated as such at more, we know there is obstruction the military point of enrollment into the which will increase. The prolonged use United States army during the late Eu- of the catheter will inevitably lead to ropean war. This number does not in- infection, sepsis and a fatal end, no mat- elude, of course, all neuropsychiatric ter what care is taken. The majority cases in the army, nor does it include of cases, when referred to the genito- any of such cases rejected by local ex- urinary surgeon, are uroseptic and re- amining boards. quire as great attention as a baby in This large number of cases was di- order to prepare them to stand opera- vided for study into nine diagnostic tion. Experience has well shown the groups, as follows: Mental deficiency, folly of rushing them to operation psychoneuroses, psychoses, nervous dis- without preliminary treatment. It may eases and injuries, epilepsy, constitu- be necessary to allow the drain to re- tional psychopathic states, endocrinopa- main in the bladder for weeks. Care thies, drug addictions and alcoholism, must be taken in relieving an overdis- Out of the total number of cases of 69,- tended bladder ; sudden withdrawal of 394 exhibiting some kind and degree of large amounts of urine may prove fa- mental condition differing from the so- tal. The preliminary cystostomy should called mental normal a little more than be done under local or spinal anaesthe- 31 per cent manifested mental deficien- sia and the patient should be allowed cy. In other words, almost a third of out of bed early. Some cases may go the mental cases drafted into the army home with careful instructions as to were in some degree weak-minded, self-cure, and return some months later About 16 per cent of the 69,394 men for operation. Large amounts of wa- were psychoneurotic — that is, they ter should be taken ; the daily output manifested symptoms of hysteria, psy- should be at least 2,500 c.c. Moderate chosthenia, enuresis, stammering, or exercise s beneficial." morbid anxiety. In this group there 86 SOUTHERN MEDICINE AND SURGERY February, 1922. were a few cases of nervousness result- centage of mental defectives was no- ing from injuries and a small number ticeable amongst enlisted Jews. The of cases not definitely diagnosticated, same statement is true of those of Irish Of all the cases diagnosticated as hav- blood, whether born in the United States ing some sort of psychosis — that is, as or in Ireland. Weak-mindedness is ap- being insane, the percentage was a lit- parently not an Irish defect, tie more than 11. The epileptics num- These diagnostic studies have inter- bered 9 per cent. The so-called consti- esting significance with reference to al- tutional psychopaths constituted almost coholism and drug addiction. The ne- 9 per cent of the total 69,394 men. In gro, contrary perhaps to the expectation the group called psychopaths were in- of the average Southerner, was found eluded the inadequates, those emotion- not to be alcoholic, in the sense in which ally unstable, those of paranoid person- the term was used. Amongst the French ality; the criminally and the sexually and the Scotch alcoholism was found to inclined. The individuals in this group be considerably above the average for were not weak-minded, but they were the United States. The Irish, true to undependable. The endocrinopathies — expectations, showed in their drafted or those affected by ductless glandular men the proverbial fondness for whis- imbalance — accounted for almost 7 per key. cent of the 69,394. The thyroid gland These studies indicate that feeble- was found responsible for the disorder mindedness and alcoholism was found in almost 90 per cent of the entire more prevalent in those races in which group. Scarcely 3 per cent were drug the standard of intelligence is high — ■ addicts, and only 2.8 per cent were so- especially the Scotch, the French and called alcoholics. the Irish. Neither do the figures dis- It will be noted that of all these 69,- close indications that insanity is more 394 men found to be in some degree prevalent amongst those races in which neuropsychiatric — that is, nervous or alcoholism is most prevalent. With ref- mental cases — almost a third were erence to alcoholism and mental defi- feeble-minded. The degree of feeble- ciency Bailey thinks the data sufficient mindedness was such indeed that 90 to justify the conclusion that weak- per cent of these cases had to be re- mindedness and alcoholism do not exist jected because of inability to adjust together. One implies absence of the themselves to the exigencies of military other. The conclusion is reached that life. Consequently, more than 19,000 insanity is not so prevalent amongst of the 69,394 were rejected on account people in whom mental defectiveness is of poor mental development. a striking feature. Relative absence of A study of these figures with refer- mind, it would seem, tends to exclude ence to certain races is of interest. For its liability to its disorder, instance, these data indicate that the Syphilis was found to be exceedingly percentage of feeble-mindedness among prevalent amongst the drafted negroes, negroes is almost twice as great as Of all the black people in the group of among the white people of the United 69.394 neuropsychiatric cases more than States as a whole. The Mexicans show- 57 per cent were syphilitic, while only ed a larger percentage of feeble-mind- 22 per cent of the whites were so in- edness than the negro, and so did the fected. The conclusion was reached that American Indian, although in these two alcoholism is not a very important fac- latter races the number of cases sub- tor in the spread of syphilis, inasmuch mitted for study and diagnosis was as the negro drafted men were not al- small. The Italians and the Russians coholic. likewise showed a higher percentage of Bailey discusses briefly the possible feeble-mindedness than the native interpretation of mental defectiveness, whites of the United States. Those of Does it indicate a biologic condition im- German blood, whether born in the plying that the race is in an early state United States or foreign-born, exhibited of development and that the mental a relatively small percentage of weak- level is normal for that particular pe- mindedness. The Scotch were almost riod or evolutionary up grade — that is, entirely free from evidence of inherent does racial mental defectiveness imply mental defect. The English and the an infantile state of mind, or must we French were at the level of the United understand that mental defectiveness is States for mental deficiency. A low per- the manifestation of a devolutionary February, 1022. ' EDITORIAL 87 process— the result for instance, of vation is of interest both as additional inbreeding amongst defectives? The testimony of the curative value of sun question at this time seems without an light in this disorder, and as evidence answer. It would seem, however, so that the curative process occasioned bv Bailey concludes, that low mental devel- these divergent therapeutic agents will opment in the negro, the American In- probably be found to be fundamentallv dian, and the Mexican, makes each of the same. These results establish a these races inferior to the neighboring chemical basis for the use of heliother- white race, and this mental deficiency apy in rickets. Furthermore they fur- unfits each of these races for successful nish the first definite evidence of meta competition with the white man. boiic change in the animal body brought The article is not conclusive; it is about by the solar rays. suggestive, and for that very season it 1_ deserves careful, thoughtful reading Prevention of Development of Rickets and re-reading. in Rats by Sunlight. G. F. Powers and E. A. Park, New Haven, Conn. ; P. G. Shipley, E. V. Mc- CoUum and Nina Simmonds, Baltimore (Journal A. M. A., Jan. 21, 1922), assert that light cannot be left out of account m the study of any nutritional problem. Pediatrics Yates Faison. M. I).. Dept. Cure of Infantile Rickets bv Sunlight, [^r/h'^^f f^^""" °y]'^u^^^• '"P^'^ "^""^ . ouiiuMiii. j„ the future modify the dietary of pris- Nine rachitic infants were placed by oners, miners and all individuals who by Alfred F. Hess and Margaret B. Gut- occupation or other circumstances, are man, New York (Journal A. M. A., Jan. deprived of their optimal exposure to 7, 1922), in the direct sunlight for from '^^ht. A certain amount of light must one-half hour to several hours, the pe- o^ considered essential to optimal health riod varying according to the sun's in- ^"<^ development, just as are air, food, tensity, the clemency of the weather, ^^'ater and a proper relation between and the sensitiveness of the baby. Care temperature and humidity. That is, was taken that the infants were warm, ^^sht rays are absorbed and utilized in It was found (luite sufficient to expose carrying on the normal body functions, the arms and legs, although it is prefer- However, Nature has apparently fur- able, when the temperature permits, to "i-'^^ied, in an organic substance con- expose the trunk as well. Previous ta Gained in cod liver oil and elsewhere, a treatment, the majority of infants -substitute for light, and the individual showed the clinical symptoms of mild ^^'^o is deprived of light can apparently rickets, characterized by beading of the adapt himself to the condition, provided ribs, and the characteristic changes in this factor is contained in his diet in the epiphyses as seen by roentgen-rav sufficient quantities. In this way, light examination. All the children were re- ciitfers from air. Although it is essen- ceiving the customary milk mixtures tial to optimal function under conditions and orange juice, the older ones getting normal for the species, it is not essen- cereal in addition. Reliance was not tial if certain factors contained in the placed entirely on the roentgen-ray ex- tish oil are provided in sufficient abund- amination of the bones. In every in- ance in the food. Either light or cod stance in which heliotherapy was em- 'iyei* oil will prevent or cure rickets, ployed, the rachitic signs diminished, as Either permits the child or the rat to was demonstrated clinically and by ro- adapt itself to pathogenic variations of entgen ray, and the general condition the calcium-phosphate ratio in the diet, improved. The inorganic phosphorus of ^"^ it is because of the existence of the blood of the rachitic infants decreas- these two protective substances, appar- ed from month to month, starting gen- ently so widely different, that the con- erally below 3.5 mg. per hundred cubic fusion has grown up about the etiology centimeters of blood, and gradually be- of this disease. How the sunlight acts ing restored to the normal level of about f^ ^^^^.,«„ „^„ 4-„^-- + / ui 4 mg. This result is similar to that ^?. P'?.^"'^ adaptation to unfavorable which has been attained by means ef stimuli is not known. Two possibilities, cod liver oil, which must be considered however, suggest themselves. Light a specific for this disorder. This obser- may mobilize a chemical factor in the 88 SOUTHERN MEDICINE AND SURGERY February, 1922. body from tissues which contain it, per- anatomy and physiology in the schools. Such haps the fat, thymus, spleen or lymph Instruction is calculated to be of far more ,.^ a t1 1JU1 benefit to the school child as a future citizen. tissue. Such a process would be anal- ^^ile correction of defects in physique or OgOUS to the mobilization of the leuko- health is a tremendous problem in itself, it cytes in the blood by radiation. The dis- only scratches the surface of what needs to charge of this factor may occur through be accomplished in preventive medicine. In or without accompanying destruction of *\™trfrateJ?,rb'eS:„r„VtriSo'St' the tissue reservoir by light. The sec- suits.— (Ohio State Journal.) ond possibility is that cod liver oil and There is a period in, the life of every light supply the body cells with the child when he is most subject to im- same thing. We know that many oils pressions, be they good or evil. This emit light during the process of oxida- period is considered as existing in the tion, and it may be that the oil actually early part of his grammar school life, radiates the tissues of the recipient. In in Toledo the work of health super- this event, healing of rickets by cod vision in the public schools has pro- liver oil would come about through the gressed in the last ten or eleven years agency of a physical or physicochemical so that we are thinking in new terms. force rather than as a tissue reaction Perhaps, in the beginning, we had the to a ponderable chemical substance. It vision but did not fully comprehend the is not impossible that vitamins may responsibility or understand our oppor- have to be sought among the organized tunity for approach to the child in the chemical compounds. formative period. Health work in the schools was inau- Purpura Fulminans During Convales- gurated so that school attendance would cence From Scarlet Fever. be improved, and that there would be Guthrie McConnell and Harry L. full opportunity for a child to secure Weaver, Cleveland (Journal A. M. A., greatest good from the teaching scheme. Jan. 21, 1922), report the case of a girl. The idea of disease prevention by re- aged 6, in whom, the fifteenth day af- moving or alleviating the handicaps of ter the first symptoms of an attack of childhood was basic. There has been a scarlet fever and the seventh or eighth fu" realization that focal infections had dav of normal temperature, the tem- an immeasurable influence on health, perature went up suddenly to 40 C. (104 We have sought to detect the various P.). The same day, the patient's left defects of nose, tonsils, and teeth, also foot became discolored ; further ecchy- the poor functioning eyes or ears. We moses appeared on the body in the have endeavored to diagnose the heart, course of about forty-eight hours ; the the lung, or other body disabilities that urine and stools became bloody, and the are a menace to the child's future wel- fourth day after the first ecchymotic fare. After learning the presence of a area was seen, the patient died. The handicap, the parent has been informed postmortem examination revealed, in of the lesion and urged to take steps to addition to the skin ecchymoses, hem- secure treatment and alleviation. Such orrhages in the bladder, intestine and a program has been amplified by work- brain. Microscopic examination reveal- "ig with some corrective agencies of a ed that the discoloration was not due to more or less philanthropic character, gangrene but to interstitial hemorr- such as the District Nurses and Thahan hages following infectious thrombosis. Dispensaries. When impossible to secure aid for the handicapped child through the family, it has been possible through our dental clinics and also by using various altru- istic specialists, along eye and ear or orthopedic lines. THE SCHOOL CHILD— THE FUTURE Prevention and Correction CITIZEN* The corps of physicians and nurses _ „ „ „ , „ r. r^ , , has been increased from time to time By P. B. Brockway, M.D.. Toledo. ^^^ y^^ j^ ^^^ been felt that the results Editoi-'s Note.— Real basic and easily ab- were not all that we wished to achieve. sorbed health-habit education is a necessary ■m-.-u ii efforts wp werp nnlv car safeguard for our democracy. Health habits ^^IV ^^^ ^"^ eiTOrtS we were only cor- and social hygiene, in the estimation of Dr. recting a small portion of the defects Brockway, should be taught in preference to that were preventable. This was made State Medicine McBrayer, M. D., Dept. Editor February, 1922. EDITORIAL evident when examinations for working admission, or else removed all quaran- certificates were begun. Then it was tine barriers, so that those who desire that we learned how many boys and might have full privilege to secure this girls had not received proper treatment, disease. and therefore were not ready to take Teaching Health a place in industry without being men- There is no well considered plan, so aced thereby. far as I know, of teaching health hab- We believe that the child of today its in a definite way in any school sys- should have ideas of health and life so tem in this country. The physiology definitely a part of his character that and hygiene as taught are usually so his future family will have the benefit, dry and uninteresting that children ab- Only by such training will our future hor them, and seldom realize that in citizens be the men our country de- those studies, lies the keystone of their serves to have. One may ask, what of future efficiency. the mentally deficient and the physi- Last year, Toledo was given the op- cally crippled? We believe they are a portunity to do some pioneer work in problem that is being solved through revamping and modernizing the facts segregation, and training to their limit, of health, hygiene and physiology. A But, of course, the vicious feeble-mind- physician, with several years' experi- ed need reproduction control, while ence in grade teaching, was employed those with substandard brain tissues to devote her time to the task. There can be trained to perform many of our was no idea of casting out the text book menial tasks. As was once said, there or skeletons, but rather to keep them is no cure for feeble-mindedness and it in the background and build upon them is fortunate that the world has work a real and practical teaching plan that even for these. would cause the children to learn health However, the fact remains that many habits and make them a part of them- of the handicaps we now discover, are selves. By so doing it is certain that preventable through education. I mean diseased tonsils and adenoids, imperfect education in the broad sense. We are articulation of the teeth and carious giving the children and parents, pres- teeth themselves, will be vastly less ent and future, data regarding proper frequent, to say nothing of the anaemia habits of eating, and making plain the and poor nutrition, with its frequent ac- value of being in a condition of perfect companiment of lung, heart or other nutrition. body lesions. We preach the gospel of wholesome. The time that is allotted in the school properly cooked food. We teach that schedule to physiology, 15 mmutes a food taken into the mouth where masti- flay, is used to present f Planned series cation is performed by healthv, pus-free of ideas along real health and hygiene teeth, aids in raising the body vitality lines. Health habits rather than an- and gives greatest resistance to disease, atomy and physiology are taught. We show the relation of good sleeping An outline and suggestions for each conditions, with requisite ventilation, to month are sent to the teacher, ihe the resistance of the lungs to tubercu- topics include the use of the handker- lar infection. The open-window room chief to guard against infection trom demonstrates the virtue of air as a sneezing and coughing, the proper pro- stimulant to the white corpuscle, in its tective treatment of the teeth, the vir- fight against the disease of childhood, tue of cleanliness, fresh air, and good, The disease incidence has been marked- properly prepared food, ly lessened among the pupils in these Social Hygiene rooms. ^^_^ The work is interwoven with the in- Education concerning vaccination has struction in home economics and man- been placed in the background. Our ual training. The nurses emphasize the people are told regarding its protective teachers' efforts by devoting an hour or value in every way, but there is no com- more each day to teaching the facts of pulsory law for pupils. The present health habits from a professional point status will continue, I am sure, until of view. The "Little Mothers' Clubs" many innocent persons experience need- presided over by the nurses, have given less illness. I wish that the State law an opportunity for the implanting of made vaccination mandatory for school some ideas concerning social hygiene. SOUTHERN MEDICINE AND SURGERY February, 1922. Orthopaedics Alonzo Myers, M. D., Dept. Editor We believe that the social hygiene problem is most properly to be solved by the parent. However, few parents are ready for, or will accept, the re- sponsibility. We are endeavoring to reach the future parents and give them _. ^^, ^ ,^ t--j- the basic principles, so that they may Disease of the Tarsal Scaphoid m be guarded and informed and ready to Young Children -Abrahamsen, Re- assume the rightful responsibilities of vue d Orthopedie, July, 1921, p. 313. parenthood ^^^^ P^P®^ ^^ " ^^^^^ report of a case I believe we are taking part in a con- of Kohler's disease which showed im- structive scheme to show the use of provement under thyroid treatment. A sex in human individuals. We are en- boy of seven, born of healthy parents deavoring, through education, to give and with no previous history of illness the proper relation to behavior or con- oy ^".lury, began to limp and to com- duct and character. Pl^i" fj fitting tired easily although ,^ • 1 . -J ^i, i he walked without support of any kind. If we can inculcate proper ideas that gvmptoms were in the right foot. This will become the fabric of life of our ^^^^ ^^^ ^^^^^1 -^ appearance. There boys and girls, we shall have made them ^^^ ^^ -^ ^^ pressure and no limita- able to absorb the most from their ^.^^^ ^^ ^^^-^^ ^^^ ^^1^ ^^^^^^ ^^^^_ school environment. Whether heredity ^^ ^^ ^^^ ^^ ^^ 2 cm. The roentgeno- or environment are of greater influence ^^^^^^ ^^^^ ^^^ scaphoid was al- ls a mooted question, but in the United ^^g^ absent States, which is a democracy, every Powdered 'thyroid gland was given 15 man is supposed to do his own part. centigrams a day. At the end of three What that part is, can only be deter- months the bony part of the scaphoid mined by training the mental capacity was 7 mm. thick, and in two months to the limit. The ideals as well as ideas more it was 9 mm. The disease is re- must be guarded and guided, for only garded as an anomaly in development. by so doing can we have citizens who will be "fit to fight" and "carry on" in Kohler's Disease— George I. Bauman, civilization's progress. Civilization is a M.D., Journal A. M. A., October 1, strenuous affair with impulses or appe- 1921. tites and compulsions which are diffi- The author gives a brief resume of cult for the primitive man to co-ordi- Kohler's description of the disease in nate, and I fear many of us are still, 1908. Dr. Bauman concludes that "the by inheritance, primitive men. most one can say is that it is probably As a result there is frequently a an osteitis due to trauma or absorption struggle between the primitive instinct from some focus of infection, and that and high ideals, and we are approach- this osteitis interferes with the normal ing the time when one or the other development" of the scaphoid bone. He must give way. Either the responsibil- reports two cases, and the paper is il- ities of life must be reduced and the lustrated with two excellent half-tones march of civilization stayed, or a bet- of skiagrams. The treatment consists ter race of men with greater heredi- of plaster splints and crutches for two tary abilities must be bred. or three months. Civilization must be and will be pre- served and if society is really to ad- Function in Relation to Transplantation vance from age to age, the nature of of Bone— S. L. Haas, Annals of Sur- men, must improve as well as his en- gery, Sept., 1921, p. 425. vironment. In order to determine the role played Real basic and easily absorbed health- 5^ function in the growth of bone in- , v-4- J i.- • ^ J dependently of all other factors, the habit education is, for our democracy, ^^^^or performed a series of experi- a necessary safeguard. ments on dogs. In one of the series of 225 Michigan St. experiments he removed the first me- — ; tatarsal bone and replaced it in its nor- *Read before the Medical Section of the Ohio mal bed, and in the second series he state Medical Association, during the Diamond removed the metatarsal bone and trans- Jubilee Meeting, at Columbus, May 3-5, 1921. planted it into the deep muscles of the February, 1922. EDITORIAL 91 - back. Function is then established by This was found to be correct, and it was allowing the dogs to run about and ob- further shown that there was no con- servations were made at periods vary- nection between the fistulous tract and ing from 48 days to three years. The the alimentary canal. The obstruction conclusions arrived at were: was apparently at the junction of the 1. Function exerts definite influence hepatic with the common duct. Imme- on the viability of a transplanted bone, diately after the injection of the bis- 2. Free bone transplants when sub- muth paste the patient developed dis- ject to stimulation of normal function comfort in the region of the liver. It undergo a slower degeneration than gradually grew worse and in twelve similar transplants that are not under hours he began to have extreme dis- such functional influence. tress, and morphin was required to re- 3. Bone transplants from old animals lieve the pain. In twenty-four hours are more resistant to absorption and he had developed jaundice. At the end degenerative processes than those of of thirty-six hours, the paste gradually young animals. began to come out through the external 4. From a practical standpoint the opening, the bile began to flow, and the institution of function at the earliest distress of the patient was much less, possible moment is advisable in order The third roentgenogram, taken at this to aid in insuring success in the opera- time, showed the paste, which had ex- tion involving transplantation of bone, tended to the margin of the liver, to be but this early function should not be disappearing; and the tube, which was established if it jeopardizes the possi- given the patient to swallow fifteen min- bility of bony union between the trans- utes previously, to be looped in the plant and the host, a condition that is stomach. Two days after the injection essential and of prime importance. of the paste, the jaundice was less and the patient had no discomfort. More Roentgenology H. Lafferty, M. D.. Dept. Editor of the paste came out, and the bile be- gan to flow freely. On the fourth day the liver was almost free from bismuth. The patient was apparently no worse for the mechanical obstruction to his Injection of Bile Ducts With Bismuth liver for a period of forty-eight hours. Paste. Charles F. Tenney and S. H. Patter- son, Toledo, Ohio (Journal A. M. A., Jan. 21, 1922), relate the case of a man on whom a cholecystectomy was per- formed. The patient made an unevent- Hospital and Sanatorium John Q. Myers, M. D., Dept. Editor ^^:^\!^Z 'f!:sturSt;d'"Sn The N-th Caronna nospit^^^^^^^^^^^ order to determine the extent of the ^^''T"^ u\^^'Mf i^^n^^f N P Tan fistulous tract and its relations to the Sheraton Hotel, High Pomt, N. C, Jan- duodenum, the duodenal tube was pass- "^^^ ^^' ^'^'^'^' , ^ ^ , u ed and a small amount of milk, con- The meeting was called to order by taining barium, was injected into the Dr. H. B. Hiatt, Chairman Committee tube, to make clear its outline. At the of Arrangements, High Pomt, N. 0. same time, three-fourths the contents Prayer by Rev. W. A. Lambeth, Wes- of a one-ounce tube of bismuth paste ley Memorial M. E. Church, High Point was injected into the external opening N. C. Address of welcome on behalf ot of the fistula. The paste passed in with the City of High Point by Hon. Jno. W. slight pressure and caused no pain. A Hendrick, Mayor. Address of welcorne roentgenogram was immediately taken ; on behalf of the Guilford County Medi- and it was found that the liver ducts cal Society by Dr. John A. Wflliams, of were extensively injected with bismuth Greensboro, N. C. Response to these paste. Before the second picture was addresses by Dr. James M. Parrott, Kin- taken (fifteen minutes later), the pa- ston, N. C. tient was given buttermilk and barium Dr. John T. Burrus, President of the to drink, so that the stomach might be Association, delivered a most interesting outlined and assurance had that the presidential address, "Our Duty to the duodenal tube was in the duodenum. §ick." SOUTHERN MEDICINE AND SURGERY February, 1922. The meeting was largely attended — more than one hundred North Carolin- ians in attendance. Dr. Howard A. Kelly, of Baltimore, Md., delivered the evening address on his experience in handling the "Cancer Problem." His address was well taken and received much applause. There were several round table talks by the doctors and representatives from the Nurses' Association, who discussed the many problems now confronting the hospitals and the nurses' training schools. The nurses' training schools were discussed at length. This was the most enthusiastic meet- ing the North Carolina Hospital Asso- ciation has ever held. Several commercial exhibits were on display. The exhibitors were well pleas- ed with the meeting. Dr. J. A. Williams, of Greensboro, N. C, was elected President for 1922. Dr. James R. Alexander, of Charlotte, N. C, was elected Secretary-Treasurer to suc- ceed Dr. John Q. Myers, of Charlotte, N. C, who has served since the organiza- tion of the Association. The next meeting will be held at Wil- son, N. C, the time to be decided upon by the Board of Trustees. Names of the Trustees: Dr. J. M, Parrott, Kinston, N. C. ; Dr. L. B. Mc- Brayer, Sanatorium, N. C. ; Dr. J. W. Long, Greensboro, N. C. ; Dr. John Q. Myers, Charlotte, N. C. "Our Relation to Other Folks"— Dr. L. B. McBrayer, Sanatorium, N. C. "The Management and Functions of a Small Hospital Laboratory"— Dr. Frederick R. Taylor, High Point, N. C. "In What Ways Can Hospitals Co- operate in the Public Health Work?"— Miss Lula West, Superintendent Martin Memorial Hospital, Mount Airy, N. C. 6:30 P.M. Banquet at Sheraton Hotel by the Committee on Arrangements and Mem- bers of High Point Hospitals. 8:00 P. M. Address by Dr. Howard A. Kelly, Bal- timore, Md. 9:00 P. M. Lantern Slides and Address — Dr. John Wesley Long, Greensboro, N. C. Publications Received PROGRAM 10 A. M. Call to Order Fourth Annual Meeting North Carolina Hospital Association — Dr. H. B. Hiatt, High Point, Chairman Committee of Arrangements. Invocation — Rev. W. A. Lambeth, High Point, Wesley Memorial M. E. Church. Address of Welcome on Behalf City of High Point — Hon. Jno. W. Hedrick, Mayor. Address of Welcome on Behalf Guil- ford County Medical Society — Dr. John A. Williams, Greensboro. Response to Address of Welcome on Behalf North Carolina Hospital Asso- ciation— Dr. James M. Parrott, Kinston. President's Address — Dr. John T. Burrus, High Point. "The Practical Importance of Minor Details in Hospital Work"— Dr. J. F. Highsmith, Fayetteville, N. C. SOUTH AMERICA FROM A SUR- GEON'S POINT OF VIEW. By Franklin H. Martin, C.M.G., M.D., F.A.C.S., Director General American College of Surgeons; Managing Edi- tor, Surgery, Gynecology and Obstet- rics. Introduction by William J. Mayo, M.D., F.A.C.S. Price $3.00. The Fleming H. Revell Co., 158 Fifth Ave., New York City. One of the most interesting and in- structive travel books of the day. It is of especial interest to the medical pro- fession, and of peculiarly especial in- terest to the medical profession of the United States because it so vividly and completely portrays, not only the gen- eral facts of interest about South America, but also the existing status and every day life of her doctors and hospitals. Human nature and people are always interesting to know, but 'tis a trait of humanity to be more interested in mem- bers of our own family ; and the great American family are certainly bound together by the strongest ties of com- mon ideals and ideas looking toward the attainment of the very highest degree of civilization. Former environments and paths of travel have not given the opportunities for an intimate acquaintance and rela- tionship between the two new and kin- dred continents, and, besides, each con- tinent has been so occupied with its own problems of founding governments February, 1922. BOOK NOTICES 93 and laying cornerstones upon which to build a bigger and grander civilization that we have not realized fully until now the fact that our paths are pa- rallel. Dr. Martin in his own inimicable style summarizes his observations made on two trips to this sister continent, and does it in such a brief but enter- taining way that the reader actually forgets but that he himself steps aboard the comfortable S. S. Ebro and leaves the biting February cold of New York harbor and drifts out and south into the luxurious balm of the gulf stream, the semitropics of the Florida coasts into the dream visions of a ver- dant, tropical Panama. You may un- consciously edge your arm chair clcser to your radiator as a February blizzard howls outside and about your windows, but even this cannot distract your at- tention and you go on, in imagination enjoying delightful evenings on deck or the unique and unrivaled welcome ex- tended by the new friends you are meeting at luncheon and in homes, friends who typify the highest and best in the life and thought of the various South American countries you pass through. You visit hospitals, great and won- derful institutions, equipped with every modern and scientific adjunct which is utilized by a staff of highly trained and efficient doctors and surgeons in their daily work of ministering to mankind and relieving his ills. With dreamlike swiftness, as the pages turn, you are carried from one surprise to another and on every page is a wealth of information that broad- ens the perspective of life and kindles new fires of inspiration to dare and do — an instinctive reaching out to grasp that star to which in youth your wagon was hitched. Perhaps in all the world and in all the history of man, no class of persons have held in their hands a more vital influence on the peoples about them than have the doctors. If the doctors of these two continents can get better acquainted, it will do more toward ce- menting the ties of fellowship and brotherhood of the entire population of these countries than can any other in- fluence. This book is written by a doctor and addressed to doctors. It is fascinating- ly interesting but true to the core. Once you have read it you will always be glad for the broader vision of life which it gave. News Items PRELIMINARY PROGRAM TWENTY-FOURTH ANUAL SESSION OF THE TRI-STATE MEDICAL ASSOCIATION OF THE CAROLINAS AND VIRGINIA Norfolk, Virginia February 22-23, 1922 OFFICERS— SESSION 1922 Pre.sident Dr. W. \V. Fennell Rock Hill, S. C. Vice-Presidents Dr. .J. T. Burrus High Point, N. C. Dr. H. R. Black Spartanburg, S. C. Dr. Karl S. Blackwell Richmond, Va. Secretary-Treasurer Dr. James K. Hall Richmond, Va. EXECUTIVE COUNCIL One- Year Term Dr. F. C. Rinker Norfolk, Va. Dr. W. O. Spencer Winston-Salem, N. C. Dr. Julius H. Taylor Columbia, S. C. Two- Year Term Dr. W. L. Peple Richmond, Va. Dr. J. P. Matheson Charlotte, N. C. Dr. Chas. A. Mobley Orangeburg, S. C. Three- Year Term Dr. J. T. McKinney Roanoke, Va. Dr. C. O'H. Laughinghouse Greenville, N. C. Dr. D. L. Smitii Spartanburg, S. C. LOCAL COMMITTEE OF ARRANGEMENTS Representing the Norfolk County Medical Society — Dr. Southgate Leigh. Chairman; Dr. W. E. Driver, Dr. N. M. King, Dr. Jas. W. Hunter, Dr. F. D. Wilson, Dr. G. B. Byrd. Representing the Chamber of Commerce and the Board of Trade— Mr. F. R. Ford, Mr. A. P. Long, Mr. W. A. Parker, Mr. R. D. Da- vis, Mr. Chas. McDermott, Mr. N. S. Horton. PRELIMINARY PROGRAM Wednesday, February 22, 10 A. M. Place of Meeting — Monticello Hotel. The Association will be called to order by Dr. Southgate Leigh, Chairman of the Com- 94 SOUTHERN MEDICINE AND SURGERY February, 1922. mittee of Arrangements. "The Value of Psychoanalysis to the Gen- Invocation— The Right Reverend Beverly D. eral Practitioner," by Dr. Louis E. Bisch, Tucker, Bishop of Southern Virginia. Asheville, N. C. Address of Welcome on Behalf of the City— "Rambling Remarks in Re Appendicitis," by Hon. A. L. Roper, Mayor of Norfolk. Dr. Stuart McGuire, Richmond, Va. Address of Welcome on Behalf of the Nor- "Headaches with Especial Reference to folk County Medical Society— Dr. C. J. An- Those Due to Sinus Infection," by Dr. H. C. drews. President of the Norfolk County Medi- Shirley, Charlotte, N. C. cal Society. "Don't Convict Your Patient on Circum- Response — Dr. Frank M. Lander, Williams- stantial Evidence," by Dr. D. Lesesne Smith, ton, S. C. Spartanburg, S. C. President's Annual Address — Dr. W. W. "Some Disturbances of Pernicious Anaemia Fennell, Rock Hill, S. C. Other Than Blood Changes," by Dr. Henry A. Papers Christian, Boston, Mass. (invited guest). "Duodenal Ulcer and Cholecystitis," by Dr. "Cancer Propaganda" (Illustrated with Warren T. Vaughan, Richmond, Va. Lantern Slides and Moving Pictures), by Dr. "Acute Perforation of Duodenal Ulcer," by J. W. Long, Greensboro, N. C. Dr. George H. Bunch, Columbia, S. C. "The Course of Recovery Following Opera- "The Spleen in Surgery," by Dr. Carrington tion for Permanent Facial Paralysis" (Lantern Williams, Richmond, Va. Slides), by Dr. C. C. Coleman, Richmond, Va. "The Treatment of Chronic Empyema," by "The Surgical Treatment of Facial Neural- Dr. F. S. Johns, Richmond, Va. gia" (Lantern Slides), by Dr. Addison G. Bre- "Repeated Perforations of the Small Intes- nizer, Charlotte, N. C. tine of Undetermined Origin," by Dr. S. S. "The Relation of Modern Dentistry to the Gale, Roanoke, Va. Practice of Medicine" (Lantern Slides), by Dr. "Surgical Research," by Dr. John B. Deaver, Guy R. Harrison, Richmond, Va. (invited Philadelphia, Pa. guest). "Some Points of Differentiation Between "Blood Pressure in Pregnancy," by Dr. J. N. Kidney and Intra-Abdominal Lesions," by Dr. Upshur, Richmond, Va. A. J. Crowell, Charlotte, N. C. "Auto-Transfusion," by Dr. Charles S. "Torsion of the Spermatic Cord; with Gan- White, Washington, D. C. grene of Testicle; Case Report," by Dr. Ham- "Sarcoma of the Long Bones," by Dr. James ilton W. McKay, Charlotte, N. C. W. Gibbon, Charlotte, N. C. "The Differential Diagnosis of Some States "Report and Discussion of Urological Cases of Torpidity," by Dr. Tom A. Williams, Wash- (Polycystitic Kidney)" (Lantern Slides), by ington, D. C. Dr. N. Bruce Edgerton, Columbia, S. C. "Pertinent Considerations in Hypertension," "Management of Urological Cases," by Dr. by Dr. W. W. Silvester, Norfolk, Va. Joseph F. Geisinger, Richmond, Va. "The Treatment of High Blood Pressure," "Uretero-Pyelography" (Lantern Slides), by by Dr. Garnett Nelson, Richmond, Va. Dr. Stanley H. Graves and Dr. S. B. Whitlock, "Reconstruction Surgery" (Illustrated by Norfolk, Va. Lantern Slides and Moving Pictures), by Dr. "Neoplasmata of the Clitoris," by Dr. F. H. Albee, New York, N. Y. (invited guest). Frank D. Worthington, Charlotte, N. C. "Therapeutic Impressions," by Dr. Ivan P. "Nitrous Oxide-Oxygen, Analgesia and An- Battle, Rocky Mount, N. C. aesthesia in Obstetrics," by Dr. G. Bentley "Reflections on Medical Ethics," by Dr. Da- Byrd, Norfolk, Va. vis Furman, Greenville, S. C. "Tuberculous Joints," by Dr. Alonzo Myers, "Some Further Observations and Reports of Charlotte, N. C. Cases in the Instillation Treatment of Enure- "A Study in Pericarditis," by Dr. W. B. sis in Childhood," by Dr. William R. Barron, Porter and Dr. F. M. Hodges, Richmond, Va. Columbia, S. C. "The Value of Early Exploration in Obscure "Group or Rather Co-operative Practice," by Intra-Abdominal Conditions," by Dr. D. T. Dr. J. E. Rawls, Suffolk, Va. Tayloe, Washington, N. C. "Torsion of Appendices Epiplociae; Case Re- "Surgery and the Haemophiliac," by Dr. J. port," by Dr. Samuel Orr Black, Spartanburg, H. Taylor, Columbia, S. C. S. C. "The Tax-Supported Doctors' Propaganda "Increasing Use of Narcotic Drugs by Mem- for Socialized Medicine," by Dr. M. Eugene bers of the Medical Profession," by Dr. W. C. Street, Glendon, N. C. Ashworth, Glenwood, N. C. "A Criticism of the Prohibition Law," by "Psychoanalysis," by Dr. W. A. White, Dr. R. E. Hughes, Laurens, S. C. Washington, D. C. (invited guest). "Practical Use of Current Medical Liters- February, 1922. EDITORIAL 95 ture," by Dr. M. L. Townsend, Charlotte, physicians will be welcomed to all the N. C. sessions. "The Surgical Significance of Pain in the At the last meeting of the Associa- Left Side of the Abdomen," by Dr. R. L. Pitt- tion the Secretary was authorized to man, Fayetteville, N. c. limit the program to forty papers. He "Silent Stones: Report of Case.s," by Dr. W. has taken the liberty of excluding from Lowndes Peple. Richmond, Va. this number the Presidential Address Information and the papers presented by invited Norfolk is abundantly supplied with guests. The program, therefore, stands first-class hotels. The Monticello Hotel in completed form. If there are errors will be headquarters of the Association, or omissions please communicate at There are also other hotels, as follows: once with the Secretary: The Lorraine, the Southland, the Fair- Section 9: "Not more than twenty fax, the Atlantic, and the Victoria. minutes will be occupied in reading any The Association may tax the hotels paper, except by a vote of the Associa- to their capacity, and you should re- tion. In the discussion of papers, reso- serve a room at once. lutions or questions, no member shall Arrangements have been made for speak longer than five minutes nor lantern slide work, and a competent more than twice on the same subject, operator will be on hand, consequently except on special permission by a vote any paper may be illustrated if the au- of the Association." thor will furnish the slides. Space will be provided for the exhibi- The members of the Association will tion of ethical goods. Exhibitors should be entertained as well as instructed at communicate at once with the Local the meeting, but the entertainment fea- Committee of Arrangements, tures will be announced later. All For further information call freely members who wish to bring their wives upon Dr. Southgate Leigh, Norfolk, Va., and daughters with them to Norfolk or may feel assured that they will be most W. VV. FENNELL, M.D., President, cordially welcomed by the wives of the Rock Hill, S. C. Norfolk physicians. Members of the JAS. K. HALL, M.D., Tri-State will recall the royal welcome Secretary-Treasurer, Norfolk has extended to us in the years Richmond, Va. gone by. The serious business of the meeting. hovvever, is the discussion of medical income Tax Exemptions lor Physicians problems, and the hope is entertained that the author of each paper on the In addition to exemptions for depend- program will immediately take steps ents and other general deductions, prac- looking to the prompt and thorough ticing physicians may take into con- discussion of the thesis which he pre- sideration the legitimate outlay incident sents. The Secretary would like to sug- to their practice in formulating income gest to each author that he send a copy tax returns for 1921, which must be of his paper to some fellow-member for properly executed and returned to the the purpose of having the member ini- Collector of Internal Revenue before tiate the discussion of the subject. It March 15 of this year, is earnestly hoped that the discussions General Exemptions. may be prompt and lively and thorough. If married, the physician may first The program is short, but comprehen- record a deduction this year of $2,500, sive, and there will be ample time for if his income is $5,000 or less in place adequate discussion. of $2,000 last year from his gross in- There are many reasons for believing come. If single, he may deduct $1,000. that the coming meeting will be the For each child or dependent under the largest and the best the Association has age of eighteen he is allowed a further ever known. The former presidents all deduction of $400, instead of $200. as promise to meet with us again, as they last year, did last year at Spartanburg. Office Rentals. A few invited guests of world-wide If the physician owns his own house reputation will address the Association, and has his office in one room of that Come to the meeting, and bring some house, he may not claim a deduction for of your medical friends alon^. All good office rent. But if he pays rent to an- SOUTHERN MEDICINE AND SURGERY February, 1922. other person, for the use of office space, he is permitted to deduct the amount expended for the rent of that office. Automobile. Exemption may be claimed for the cost, repair and upkeep of automobile or other vehicle which is used exclu- sively in the conduct of a physician's business. The salary of the chauffeur, if most of his time is spent in driving to professional calls, may also be de- ducted. Amounts spent for the hire of taxicabs, and also street carfares, on business calls, may be taken off. Assistants. Exemptions may be claimed for the salary of a nurse, laboratory assistant, stenographer, or clerical worker in the office, whose work is connected with the doctor's professional duties. De- duction may also be made for the sal- ary of a maid or other person who spends her time in opening the door or answering the office telephone. Deduc- tions may be made for that proportion of wages or salaries paid to employes in return for service directly in connection with practice or in connection with the care or treatment of patients. Medicines, Instruments, Supplies. A doctor may take off an item for medicines used in the office in the treat- ment of patients. Bandaging, labora- tory material, and all other supplies nec- essary to the running of the physician's office are permitted to be deducted. General Office Expense. Telephone bills in their entirety may be deducted, because it is understood that the telephone in a doctor's office, even when that office is in his home, is almost entirely used for professional purposes. Exemption is permitted for the cor- rect proportion of expenditure made for light, heat and water. Depreciation of 10 per cent of the original cost each year is allowed upon office furniture, it being considered that furniture should last about ten years. Library. Most doctors have a medical library more or less extensive. In the courts it has been decided that after ten years a medical book is out of date and there- fore worthless. For this reason the doc- tor is allowed a depreciation item of ten per cent each year on his medical li- brary. Taxes, Licenses. Any taxes which a doctor may be re- quired to pay upon materials required for his work may be deducted, and all licenses which he is by the nature of his business required to take out, may be taken off of his gross income report- ed. This includes his license to pre- scribe alcohol, narcotic license, automo- bile tax, local occupational taxes and so forth. Professional Dues. Also, a doctor may deduct dues paid to professional associations to which, in the interest of his business, he belongs, and exempation is also allowed for sub- scriptions to all medical newspapers and journals. When to Deduct Unpaid Debts. If his books are kept according to the "Cash Receipts and Disbursements" system, he may not charge off any un- paid debts, because as explained in the tax manual, "if his books are kept ac- cording to this system, he is only re- porting as gross income those accounts which have proved to be good, and therefore bad accounts cannot be de- ducted because they have already been excluded. If the books be kept on an "Accrual" basis (that is, on the basis of expenses actually incurred and payable even though not yet paid, or income earned although not yet collected) , it is permit- ted that the doctor may charge on his income tax blank all debts which are definitely ascertained to be worthless during the year past. In the same way, the doctor is per- mitted to claim deductions for all other expenses within the scope of his pro- fession, and the amount of his tax is determined on the net income which re- mains after all of these items have been deducted. Richmond Academy of Medicine At the regular meeting of the Rich- mond, Va., Academy of Medicine and Surgery on January 10, officers for the ensuing year were installed. Dr. Emory G. Hill presented a paper entitled "The Problem of the Cross-eyed Child." The tendency away from operative attempts at correction was emphasized, and Dr. Hill advised the family physician against indulgence in the hope that cor- rection of the defect by operative meth- ods is either easy or satisfactory. Dr. Hill's thesis was discussed by Dr. Jo- seph A. White. February, 1922. EDITORIAL 97 Dr. Henry B. Stern presented three children exhibiting muscular dystrophy. The mysterious nature of the affection was emphasized by the speaker, and Dr. R. Finley Gayle discussed the sub- ject. A donation of fifty dollars for the treasury of the Academy was made to the tuberculosis foundation of Catawba Sanatorium in memory of the late Dr. B. L. Taliaferro. At the regular meeting of the Acad- emy on January 24, Dr. E. Guy Hop- kins discussed "Some Practical Points in Blood Chemistry." His remarks had especial reference to blood sugar exam- inations as of value in detecting the development of diabetes mellitus, and he spoke also of the importance of as- certaining retained nitrogen products either new in kind or excessive in amounts as pointing to kidney hypo- functioning. The paper was of great interest both on account of what it of- fered in clinical helpfulness as well as on account of pointing the way to a comparatively new field of laboratory investigation. Dr. J. Morrison Hutche- son spoke in appreciation of this par- ticular kind of investigative work. The thesi.s of Dr. H. Page Mauck on "Congenital Dislocation of the Hip" was of peculiar interest at this particular time because of the furore lately raised by the work of Dr. Lorenz in this field of surgery in New York. Dr. Mauck's paper was illustrated by lantern slides of a number of his own operative cases. In discussing Dr. Mauck's remarks Dr. A. L. Gray emphasized the importance of differentiating congenital dislocation from simple relaxation with lengthen- ing of the capsular ligament^ '~ and his quartet supplied the musical features. Among those present were: Drs. A. W. Knox, Hubert A. Royster, James J. Phillips, James R. Rogers, James McGee, Albert Anderson, C. O. Abernathv, Hugh A. Thompson, W. S. Rankin, C. A. Shore, A. C. Campbell, H. M. Banner, C. E. Bell, Z. N. Caviness, L. W. West, B. J. Lawrence, W. I. Rovster, Delia Dixon-Carroll, Paul N. Neal, Kemp P. Neal, Robert P. No- ble and A. S. Root. The Raleigh Academy of Medicine is the oldest medical organization in the State, and great interest is always man- ifested in its meetings. At the next quarterly meeting the Academy will be the guest of Dr. James J. Philips at his residence in Cameron Park. Dr. James C. Braswell, of Rocky Mount, N. C, and who has been asso- ciated with the Mayo Clinic, department of Eye, Ear, Nose and Throat, is now located for this work at 736 Mayo Building, Tulsa, Oklahoma. Raleigh Academy ol Medicine The fifty-second anniversary of the Raleigh Academy of Medicine was ob- served Tuesday night, February 7, at the Bland Hotel with a course dinner. Dr. A. W. Knox, president, was mas- ter of ceremonies, and Dr. James J. Phillips, chairman of committee in charge of arrangements. Dr. Hubert A. Royster, president of the North Caro- lina State Medical Society made the ad- dress of the evening. Mr. Max Kelly Proposed Neuropsychiatric School. Recommendations to the Federal Board of Hospitalization, headed by Brigadier General Sawyer, for the es- tablishment of a neuropsychiatric school have been made by Dir. Charles R. Forbes of the U. S. Veterans' Bureau. The proposal is to locate the school at the St. Elizabeth's Hospital in Wash- ington, D. C, for the instruction of medical officers of the U. S. Veterans' Bureau and the U. S. Public Health Ser- vice in the treatment of neuropsychiat- ric diseases. The director of the Veter- ans' Bureau has also recommended the purchase by the government of a hos- pital at Memphis, Tenn., for the treat- ment of disabled veterans of the South- ern district. He also announced that the reduction of the number of contract hospitals was being made as rapidly as government facilities became available and that in the future all hospitals oper- ated by the United States would be known as U. S. Veterans' Bureau hos- pitals. Approval by President Harding of the plans of Colonel Forbes for the establishment of three government re- habilitation schools was announced this week. These schools will be located on the Pacific coast, on the Atlantic coast and in the South. 98 SOUTHERN MEDICINB AND SURGERY February, 1922. Longview Hospital and means of hospitalization of insane . ^ . and nervous patients, the question of Following an inspection of Longview ^^^ necessity of federal commitment and Hospital, Cincinnati, by local represen- ^^^ disposition and permanent treat- tatives of the United States Veterans ^^^^^ ^f epileptic and mental deficients Bureau press reports indicate that the ^Yio can get along without governmen- government will build a new hospital ^^j ^^^.^ ^jn ^e the subjects of discus- for insane soldiers in Cincinnati when ^^^^ ^^ ^Yie meetings. Congress shall have made its proposed "' approprication of $16,000,000 for hos- ^^k^ Medical Society Elects Its pitalization purposes. The investigation Officers at Longview was precipitated by ^ ^ ^: ^ ^^ ^^^^ charges made by Judge Robert S. Marx, p_„„.^ Medical Societv Tanuarv 12 national commander of the Disabled V922 offiS for the ensuing year were American Veterans of the World War, fe'^^d S' dlows Pr sSt' Dr IT ro^yed^n^^Tx^lrvfcfmeT^e^ ^-^ S. Root; Vice-President, Dr. Hugh ?r d'eprTved' ofprTperTea^^^^^^^ A. Thompson .Secretary-Treasurer, Dr. sLlfan^fatTpr^vtus?^^^^^^^^ I" ^'^ presidential address Dr. Root substantiated previous reports maae Dy ^^j ^j ^ j^^ ^f ^o^k for the ensuing Dr. E A North, superintendent of the ^^ presented a program of scien- hospital to the effect that the mstitu- ^.^ ^ ^ ^J^ ^^^ discussed, tion IS housing 1 580 patients, with a ^^^^ ^f^^ ^^^^^ ^^ ^^^,^ ^ ^-^^^^ ^^^^, bed capacity of 1,340, meaning that • , ^ ., nearly 250 patients are compelled to ^"^ ^^^^ montn. sleep on mattresses placed on the floor at night. The 42 ex-service men were Bids for Hospital in Twin City Opened. not found to be among those thus ac- Bids were opened February 2, 1922. commodated, however, and they ex- for the Baptist State Hospital to be pressed themselves as satisfied with the erected in the western part of the city, treatment accorded them. The lowest bid was filed by the J. A. Jones Construction Company, of Char- Appropriation for Veterans' Bureau, lotte, the figures being $133,690. Ow- Administrative expenses of the U. S. ^^S to absence of members of commis- Veterans' Bureau are included in an in- f on, awarding contract was deferred dependent appropriation bill presented ^^^ ^ ^^Y- ^^^^- , ^^ ?^ planned to begin to the lower house of Congress. Besides construction work withm the next week covering all other contingent items, the °^ ^^^' measure carries $64,658,680 for medical „ . ^"TTTT""^, . ,, ,. , and hospital service. This is an increase Expansion of Old Electro-Medical over the appropriation for the current „, ,^ , Manufacturer. ^ ^ . , fiscal year of $6,658,680, and is in ac- ^ ^^^ Mcintosh Battery and Optical cordance with the recommendation of Company, Chicago, manufacturers of the budget bureau. The amount for \-^^y' electro-medical and physical vocational rehabilitation is $127,000,- therapy apparatus, has been reorgamz- 000. An appropriation of $160,000,000 ^^ ^1^^ ^" mcrease of capital stock un- for the payment of claims for military ^^^ ^'^^ ^^^^ ^^ ^^^ Mcintosh Electrical and naval compensation is also contain- ^corporation. , , ,. , .,.,., ed in the bill ^^^ company has established distrib- uting agencies in almost every State in the United States in the hands of local Conference of Neuropsyehiatrists in men experienced and competent to ren- -,^. , Veterans' Bureau. der service to purchasers of these goods. Director Forbes of the U. S. Veter- ans' Bureau has called a conference, Opening of Sanatorium at Dawson l*ebruary 2, of neuropsyehiatrists from Springs, Ky. various parts of the country in Wash- Assistant Secretary of 'the Treasury mgton, D. C, for the purpose of mak- CliflTord has announced that the new mg recommendations for the care and government sanitarium at Dawson treatment of former service men now Springs, Ky., will be formally opened, suffering with mental diseases. Ways February 22. The new hospital was February, 1922. EOrTORIAL 99 erected at a cost of $2,300,000. Col. H. county has agreed to serve at any time E. Whitledge, former medical officer at for as long a period as may be required. Fort Bayard, N. M., will be superintend- The command to come from a "steering ent of the Dawson Springs Sanitarium, committee" composed of Drs. John T. J. Battle, Wm. M. Jones, Greensboro, and Southern Surgical Meeting. Dr. Wm. J. McAnnally, High Point. At the recent meeting of the South- The plan includes the physical ex- ern Surgical Association, held at Pine- amination of every inhabitant of the hurst, Dr. C. Jeff Miller, professor of county and free clinics for all the rural obstetrics and gynecology, Tulane Uni- districts and health lectures in schools versify, New Orleans, was elected presi- and churches. dent to succeed Dr. Randolph Winslow, Baltimore. The new vice-presidents are : Dr. Work May Become Postmaster Drs. Vilray P. Blair, St. Louis, and Rob- General ert L. Gibbon, Charlotte. Dr. Hubert j. . *. j ..u .. t>>' tt u i. txr i A T?^,rof«v. T?oi^;^v, or,^ r\y r„Tr T It IS reported that Dr. Hubert Work, A. Royster, Raleigh, and Dr. Guy L. pj,p^ident of the American Medical As Hunner, Baltimore, were re-elected sec- ^^esiaent oi tne American Medical As retary and treasurer, respectively, ^'^ociation and now first assistant post- Memphis, Tenn., was chosen as the next ^^'^^' ^^"f^^' "^^^ ^^ "S^,f P^'^J"^'" ^or,,rir,f,-^r, ni^^r ^^^ general to succeed Will H. Hays, convention city. ^^^ j^ ^^ ^,^^.^^^ ^^ become the head of N. C. Hospital Association Meets. {^^ "^^^^^^ P^^^ure industry of the coun- The fourth annual session of the N. ^^ ' C. Hospital Association was held at High Point, January 31st, with about I^r. and Mrs. Smith to Go Abroad. one hundred doctors and several regis- Dr. and Mrs. Charles Lee Smith will tered nurses from the leading hospitals sail from New York on the 11th of Feb- of the State in attendance. ruary, on the Empress of France, for Officers were elected as follows : John an extended trip abroad. They will first A. Williams, of Greensboro, President ; visit the Canary Lslands and then go to J. M. Parrott, of Kinston, First Vice- Madeira, Portugal, Spain, Gibraltar and President; Moir S. Martin, of Mt. Airy, into Northern Africa and Egypt. They Second Vice-President; C. S. Lawrence, will go through Italy to Northern of Winston-Salem, Third Vice-Presi- Greece, visiting Constantinople and dent; John W. Long, of Greensboro, Palestine. They will also visit France, Secretary and Treasurer. Switzerland, Belgium and England, re- The new executive committee is com- turning to America the first of June, posed of J. T. Burrus, of High Point; Dr. Smith studied at the University J. Q. Myers, of Charlotte, and L. B. Mc- of Halle and Leipzig, in Germany, in Brayer, of Sanatorium. 1880, and this is his first return to the A banquet was tendered the dele- Continent since that time, gates in the evening and at a public Dr. and Mrs. Smith are leaving Ral- meeting at night Dr. Howard A. Kelly, eigh February 7th, and will spend the of Baltimore, delivered an address on interim until sailing in New York. radium and Dr. J. W. Long, of Greens- boro, gave an illustrated lecture on can- Dr. Hideyo Noguchi, a member of the cer. Rockefeller Institute for Medical Re- search, was elected to honorary mem- Seventh Centennial of University of bership in the Society of Dermatology Padua. and Venereology of Moscow at its thir- Festivities are being planned for this tieth annual meeting, October 16, 1921. spring in honor of the founding of the University of Padua in 1222. Professor Dr. Robert T. Ferguson, Gaffney, S. Lucatello, the rector of the University, C, has moved to Charlotte, N. C, with is in charge of the arrangements. offices in the Commercial Bank Build- ing, and will limit his practice to Gynec- New Plan for County Health Service, ology and Obstetrics. The Guilford County Medical Society has inaugurated a plan to provide phy- Plans are being prepared for a 20- sical examination for every citizen in room annex to the Mt. Airy, N. C, Me- the cpunty. Each physician in the morial Hospital. 100 SOUTHERN MEDICINE AND SURGERY February, 1922. The Thompson Memorial Building, of Dr. Madison Redd Drewry and Miss the Roper Hospital, Charleston, S. C, Mary Anderson Starling, both of Cas- has been completed. This will be known cade, Va., were married October 12. as the Riverside Infirmary. The old building will be remodeled and used as a Dr. Allen Fiske Voshell, Charlottes- nurses' home. ville, Va., and Miss Louise de Lancey Barclay, Baltimore, were married No- A meeting of the Fifth District S. C. vember 24. Medical Association was held in Winns- boro October 20. The followmg are offi- Dr. Ira Sephas Riggin and Miss Ruth cers of the Association : Dr. W. R. Wal- Elizabeth Bradshaw, both of Windsor, lace, President; Dr. G. W. Poovey and Va., were married October 5. Dr. W. M. Love, Vice-Presidents; Dr. G. A. Kennies, Secretary-Treasurer. j^^^ jj^^^^^ j^^g^^U Masters, Rich- „^.,,. , 'o ^ r>. ^ TVT J- 1 mond, Va., and Miss Bealmere Dare Wihamsburg, S C County Medical Li^thicum, Fredericksburg, Va., were Society has elected the following offi- j^^rried October 26. cers: Dr. W. G. Gamble, President; Dr. E. T. Kelley, Vice-President; Dr. B. M. ^^ ^,. ^ ^ , o- i, a Montgomery, Secretary-Treasurer. ^^^^- Oliver Curry Briink, Richmond, ^ "^ Va., and Miss Bernice Hall, Lynchburg, The North Carolina Hospital for the ^^^re niarried October 25. Insane, Morganton, is overcrowded and , ^r. Olivei' Allison Ryder, A exandna, notices have been sent out from the ^a.. and Miss Anne Elizabeth Potts, Hospital that no new patients can be Portsmouth, Va., were married October accepted. Mount Sinai Hospital, Norfolk, Va., ^, V"' ? tT f I^^'TT^i ^n ' was dedicated and thrown open to the ^olan Knight, both of Asheville, were public December 29. "^^^^^^^ January 3, 1922. Dr. McGuire Newton, Richmond, has DEATHS. been appointed a member of the State Luther B. Folk, Columbia, S. C. ; Med- Board of Health to fill the vacancy ical College of the State of South Car- caused by the death of Dr. Edward Mc- olina, 1875 ; served as county treasurer ; Guire. The term of office expires July died suddenly, December 12, from heart 1, 1925. disease, aged 67. Dr. Julian M. Robinson has been elect- Newton Robinson, Elizabethtown, N. ed post commander of the Danville C; Philadelphia University of Medicine Post, American Legion. and Surgery, Philadelphia, 1869 ; Con- federate veteran ; died December 20, Dr. Gerald A. Ezekiel, Richmond, has aged 74. been assigned to the Three Hundred and Fifth Medical Unit, with the rank Dirk, Adrian Guvk, Richmond, Va. ; of major, m accordance with the as- Medical College of Virginia, Richmond, signment orders for the Eightieth Di- iggS; former lecturer on ophthalmol- vision, Officers Reserve Corps. ogy, otology, laryngology and rhinology at his alma mater; died December 16, Marriages from influenzal pneumonia, aged 57. Dr. William Walton Rixey, Richmond, Va., and Hiss Helen Bradish, Char- John F. Sanderford, Creedmore, N. C, lottesville, Va., were married at New aged 57 ; died November 12 in the Watts York, N. Y., in October. Hospital, West Durham, N. C, from uremia. Dr. Frank Carleton Thomas, Roanoke, Va., and Miss Marjorie Winthrop Grif- George L. Clark, Clarkton, N. C. ; fiss, Pikesville, Md., were married No- died at his home January 24, 1922; vember 14. aged 68. February, 1922. EDITORIAL 101 Hug^h Donald Scott, Monroe, Va.; Tender Pressure Points With So-Called Medical College of Virginia, Richmond, Symptomless Gallstones. ]884; member of the Medical Society of G. A. Friedman, New York (Journal Virginia; member of the Board of Su- a. M. A., Jan. 21, 1922), states that pervi.sors ; for two sessions, member of tender pressure points in the intercostal the State Legislature; died suddenly spaces at the level of the gallbladder, in from heart disease, December 29, at the the continuation of the right axillary, home of a patient, aged 64. scapular, posterior median line are al- most always found in persons suffering William Samuel Hutchison, Anderson, from disease of the gallbladder, even S. C. ; Baltimore Medical College, Bal- when tenderness in the gallbladder re- timore, 1897 ; member of the South gion proper cannot be elicited. The Carolina Medical Association ; died De- presence of these spots is nearly as cember 29, at the Anderson County characteristic as the history in the Hospital, from chronic nephritis, aged group of so-called typical cholelithiasis. 46. Giardiasis. Dr. Edwin Gilliam Booth, Williams- Three cases are reported by Caroline burg, Va. ; University of Pennsylvania, McGill, Butte, Mont. (Journal A. M. A., Philadelphia, 1861; surgeon in the Con- Jan. 21, 1922). She asserts that giar- federate Navy during the Civil War; diasis is a frequent cause of severe died January 5, from senility, aged 82. diarrhea, with much impairment of gen- eral health. In place of diarrhea, there Dr. Peary Jackson Muncy, Ferrum, may be constipation. Practically all pa- Va. ; Medical College of Virginia, Rich- tients have abdominal pain, which at mond, 1917; died December 8, from times is very severe. Ny treatment yet pneumonia, aged 32. suggested has been successful in ridding the bowel of Giardia. Giardia may in- Dr. James Shelbourne Ewing, Jones- vade the gall bladder, and when there, ville, Va. ; Louisville (Ky.) Medical Col- and in large numbers in the duodenum, lege, 1903; died January 6, aged 46. Trauma may act as the exciting cause in the production of lesions in individ- John J. Thode, Walhalla, S. C.,; died uals with hereditary syphilis whose in- January 3, 1921. fection is dormant and even unsuspect- ed. A girl with hereditary syphilis, Andrew C. Baxter, Elloree, S. C. ; died possibly of the third generation, devel- November 4, 1921. oped epileptiform seizures and mental disturbances following a head injury causing coma. Her half-brother, like- wise infected, developed primary optic atrophy following similar trauma. The healing of the fracture produced by the same injury was markedly retarded. MISCELLANEOUS No patient who complains of persist- A Record Case. ent indigestion, or gastric distress of "Times have changed," said the any type should be dismissed lightly, bachelor, especially if that patient be over 35 "What now?" years ago. "Just called on a married couple and saw a baby being put to sleep by a lul- Role of Trauma in Lesions of Syphilis, laby played on a graphophone." — Louis- L Harrison Tumpeer, Chicago (Jour- ville Courier Journal, nal A. M., Jan. 21, 1922), is convinced — 'Snuthing. When baby gets sick that trauma may excite lesions in per- they put on one of Mrs. Eddy's records. sons with acquired syphilis whose in- fection is dormant. Bone changes, gum- The next annual meeting of the Tri- mas of the soft tissues and paretic brain State Medical Association will be held changes are the usual manifestations. February 22-23, 1922, at Norfolk, Va., may give symptoms resembling duode- with headquarters at the Monticello nal ulcer. Hotel. 102 SOUTHERN MEDICINE AND SURGERY February, 1922. PITIABLE? DISGRACEFUL? Will You, Dr. Taxpayer, Stand for This With Never a Protest? FEDERAL BOARD FOR VOCATIONAL EDUCATION Division of Vocational Rehabilitation Washington, D. C. Information No. 97 Information No. 81 re- scinded hereby. From : Assistant Dierctor for Vocational Rehabilitation To : All District Vocational Officers and Others Concerned Re: Chiropractic, Training in (Of. Information Nos. 91 and 94.) 1. Under the conditions set forth below, district vocational of- ficers are authorized to place men in training for the practice of chiro- practic. Some districts, it will be noted, have optional opportunities. Districts Nos. 1, 2, 3 and 4— Eastern College of Chiropractic, Newark, New Jersey Districts Nos. 4, 5, 6 and 7 Universal Chiropractic College, Pittsburgh, Pa. Districts Nos. 7, 8 and 14 National School of Chiropractic, Chicago, HI. Districts Nos. 9, 11, 12, 13 and 14 Palmer School of Chiropractic, Davenport, Iowa. Districts Nos. 10 and 13 St. Paul College of Chiropractic, St. Paul, Minn. 2. Before placing a man in training for the practice of chiro- practic, the district vocational officer shall secure a written statement from the man embodying the following points: (a) That he is choosing this course on his own initiative and responsibility, and will not in any way look to the Board for assistance in placement. (b) That chiropractic may be legally practiced in his state of residence or in the state in which he contemplates residing after the completion of his course. In the latter instance satisfactory evidence will be required to support trainee's intention of change of residence. 3. District Vocational officers are directed to secure from the Medical Examining Board of each state in their districts, a statement as to the .legal status of a practitioner of chiropractic. A copy of this statement must be filed in the Central Office on or before August 10. This Information No. 97 Page 2 is asked for in order that Central Office may have complete information concerning legislation that has become effective during the year 1921. No man should be put in training for the practice of chiropractic who is a resident of a state in which such practice is prohibited by law except under the condition stated in subparagraph (b) under paragraph 2 hereof. 4. Whenever possible men should be dissuaded from taking up this work, but those who insist upon being trained for it will be assigned in February, 1922. MISCELLANEOUS 103 accordance with paragraph 1 hereof. If they desire to be transferred to a designated school otherwise than as listed, they must pay their own traveling expenses. 5. The district vocational officer Dsit. No. 8 will negotiate a contract at regular rates with the National School of Chiropractic, Chicago, 111.; the district vocational officer, Dist. No. 10, will negotiate likewise with St. Paul's College of Chiropractice, St. Paul, Minn., and both district vocational officers, numbers 8 and 10, will provide all other district offices with catalogues of the two new schools designated herein. The regular procedure in regard to transfers will be followed, except as noted in paragraph 4. R. T. Fisher, Assistant Director for Vocational Rehabilitation. Doctor, note especially paragraph 4, We Wonder which "lets the cat out of the bag;" for 1. What do the medical services of it is stated to us by gentlemen in posi- the Army and Navy think of this gov- tion to know, but not by officials, that ernmental letting down of the bars to this chiropractic training was forced on quackery? the Board by congressional pressure; 2. What does the United States Pub- and it is quietly hinted that there was lie Health Service think of it? much futile anger engendered by the 3. What does the American Medical fact that the hands of the Board were Association think of it, and what did it forced by politicians. do to protest against it? Advertising Medical Skill, in the world!" n*. T?^,.oi Q r-«r^^lor,^ v^ooHii ^r^m Thcre is this to be said, how^ever. Ad- Dr. Royal S Copeland health com- ^^^^.^. ^^^j^^j ^^ill smacks very mis.sioner of the city of New York, la- ^^^^^ , %f self-praise. No man of good ments the fact that doctors do not ad- ;„1^„*,-^,, . „„;u,. ^^ +v,af pVi.tcvIqtiq vprtisp Hp dprlarps that nnbliritv con- ^^^^^ ^^'^ ^^ ^"^'^^ ^^ ^"^^- Physicians f^r^:^;. Xa-^^/Tlht facetf t;."e ;-">■; -'" »ave £.ood sense to have PQy^Vi " themselves examined. TT • J ^ ^ T^ T r Certain it is whether Dr. Copeland's He cited the case of Dr. Lorenz, of pi^^^ jg accepted and physicians decide Vienna, to whom so many crippled peo- ^^ ^ell the world what they can do for pie flocked when he was in New York ^he relief of suffering or whether the some time ago. "Dr. Lorenz," said Dr. present plan is adhered to and phys- Copeland. "did not bring with him any i^ians stick to the rigid code of ethics greater ability than at least twenty sur- ^.j^i^h now prevails, that people who geons in this city possess. It was be- fear they have some serious physical cause our doctors or our methods did ailment owe it to themselves and par- not bring home to the people what can ticularly to their families to consult a be done that we went to the distinguish- physician— the best one that can be ed foreigner to hear what he could tell found— and to act on his advice. "^- For example, Dr. Copeland said that "Here we come to the problem of ad- if the public were given more informa- vertising," he said. "The medical pro- tion about cancer, the disease would fession, through the ages, has chosen to never reach the cancerous stage. A make itself a secret thing. The doctor woman who has a tumor, he said, usu- has been looked upon as a sort of a ally keeps the fact hidden until it de- miracle man. He has hidden his wis- velops into a cancer, when it is too late. dom behind a veil of silence. An air of Any cancer, said Commissioner Cope- mystery has surrounded the profession" land, is curable in the beginning. The and we have developed a code of ethics, public must be taught that, he said. This, I believe, is the most antiquated, If the physicians feel that it is not moss covered and germ laden institution becoming in them to trumpet to the MISCELLANEOUS February, 1922. world what they can do to save the lives of minor degrees of thyroid insuffici- of the people, the people must go to th doctors with their suspected ailments Many a death could be prevented sim- ply by seeing the doctor in time. — Ra- leigh News and Observer, Feb. 9, 1922 Dr. McNairy Places Phonograph in Dairy Building. "Don't curse the cow, ency as given by Leopold-Levi, as fol- lows : 1. Transitory infiltration — a white indolent edema of eyelids, forehead, cheeks, not pitting on pressure; shoes temporarily too tight from swelling of feet ; rings difficult to remove from fin- gers. 2. Hirsute derangements — partial This was the alopecia, premature baldness, prema- advice given here by Dr. C. Banks Mc- ture grayness, premature falling of eye Nairy, superintendent of the Caswell brows or rarefaction or disappearance Training School, who planned to intro- duce a phonograph in the school's dairy of cuter third. 'i. Caloric disturbances — (a) cold- building at milking time to see what the "ess of extremities, (b) chilliness, gen- effect of music would be upon the herd eral or localized, (c) shivering fits, (d) there. subnormal temperature, (e) hypersen- Dr. McNairy is expected to make ex- sitiveness to cold, a slight draft provok- haustive experiments in connection with '"g rheumatoid or neuralgic pam, lum- "music and milk." He told a gathering bago, torticollis, or migraine, of professional dairymen and officials 4. Vasomotor derangement mani- at Kinston that a cow, being a naturallv fested in aero-asphyxia, cyanosis, chil- sensitive creature, could not give good blains, small and slow pulse, results when cuflTed, kicked, sworn at 5. Constipation susceptible to thyroid and otherwise abused. Dr. McNairy, treatment, who is the State's best-known eugenist 6. Fatigue, especially in the morning. as well as a skilled dairyman, believes "Just Break the News to Mother," "Last Rose of Summer" and "Hark, Hark, the Lark!" and other soothing or gently stirring tunes will increase the supply from the scores of handsome Holsteins at the Caswell school. At any rate, he's going to try it. 'Highly probable," was the comment 7. Anorexia — lack of appetite some- times surprisingly improved under in- fluence of thyroid extract. 8. Somnolence, especially after meals. 9. Tendency to obesity. 10. Dry, rough, harsh, thick, scaly, and ichthyotic skin. 11. Small stature. 12. Retardation of developmental of Dr. Robert S. McGeachy, head of the processes, dentition, walking, speech : health department. Many professional and dairymen, city and county oflficials at arrested developments of tastes, ovary, amateur brain, hair, teeth. 13. Tendency, on the other hand, to Kinston are to participate in a camnaign Premature senility, manifested in vari- covering several weeks in which the ^^^^ veins. slogan will be "A cow for every fam- ily." This idea will apply to rural fam- ilies only, but the whole milk business '"^^ Cancer Inf ecf ton Ochsner, in Annals of Surgery, urges will receive an impetus that is sure to the importance of taking every precau- make supplies for the city more plenti ful. Dr. McGeachy said. tion against cancer infection, notwith- standig the fact that its infectiousness has not been proved. Wise precaution There is no such word as "surprised" can do no harm, while it may do an has endless amount of good, because, in case the disease is due to infection, every ad- ditional case is a menace to others. He considers the most convincing argu- ment of the infectiousness of cancer to be found in the studies of Smith, who claims that cancer in plants is due to a micro-organism which he has been able in the lexicon of the doctor who practiced medicine the last few years Thyroid Enlargement in School Children. Stacey, in the Medical Officer, be- lieves that thyroid insufficiency is far more prevalent among school children to isolat eand cultivater and which pro. than is generally supposed. He cites duces cancer when inoculated upon the enumeration of signs and symptoms healthy plants. In human cancer fur- February, 1922. SOUTHERN MEDICINE AND SURGERY ther studies are needed, and the writer chronic pulmonary tuberculosis Du expresses the hope that these will be four has recently adopted them 'in the contmued vigorously and that in the treatment of tuberculosis glands in the meantime healthy persons be not ex- neck, and of tracheal and bronchial posed unnecessarily to cancer infection, adenopathies. His method of adminis- The fact that many competent observ- tration is: ers have been unable to prove to the 1. To prescribe 10 per cent tinctnrp satisfaction of others that they have of iodine, without the addition to iodide found the micro-organism causing can- of potash. It must be fresh for which cer must not be construed to prove that purpose only a small quanti'tv is madf^ such an organism does not exist, be- at a time, 15 grams every 15 davs cause precisely the same failures were 2. The dose is given in^half a runfnl exoerienced before the tubercle bacil- of cold milk, with which it is eft in ?an lus the bacillus of leprosy, the spiro- tact for a short time s^as to allow th^ chete of synhilis, the Plasmodium of cf>sein and iodine to react It is taken malaria, and many others were finally at the beginning of a meal, but if given discovered. Clinically, all these dis- in wine it is taken during the meal eases were intections, and it was only a 3. The susceptibility of the patients a matter of patient labor to find the must be tested, and "small doses are ^^^^"^ ^^"«e; Piven to begin with. For the first five -.. ~; days. 15 drops are sfiven twice a dnv Diagnosis of Syphilitic Aortic the dose is then increased by 5 drops Q. 1^- , .R^f "'•g't^V.''"- ""^^' 100 ^o 150 drops pro die are being Stolkind, in the Medical Press, .says taken. This amount is kept up fof that lor the dift-erential diagnosis of en- eight days, and then the dose is de- docardial and arterial aortic insuffici- creased by 5 drops every five days In S imooSancP -"^ symptoms are of chiIdren._according to age. the firk dose most importance. ^s from 5 to 10 drops pro die increas- 1. In syphilitic regurgitation the face in- to 30, 40 and 50 oVpn'rir''^"' ^" ^"'^^^-^^^^^^^l the face is 4 As soon' as the dose reaches 40 to ? Tn ;.cnc f ^ ^- , • ^. . ^0 droDs, it is divided into three. 2. In cases of endocardial insuffici- 5. If any svmutom of intolerance is ency more than 50 per cent of the pa- shown, smaller doses are used or the lents are not older than 25 to 30, while treatment is suspended for a time and n cases of svrhilitic arterial regurgita- this must be done in case of pyrexLl tion the great majority are over 35 attacks P^iexiaz years. 3. As regards the average duration Fituitrin in Obstetrics timfififin ii """1 f t'.'^f regurgita- Mendenhall, in the Indianapolis Med- IZ'lVfU f probability longer in the ical Journal, cites an impressive array 4 For Hi^v'^r-, ^- • u "^ authority against the use of this 4. l^or difi^eiential diagnosis the an- drug, and examines the possible indica- cTrS^rao";^;-. rl^'" '! °/ "^:. '" f"'°- '■''' ^°^ ''' "-• "^ -?rno on quel cardial doi tic regurgitation the patients tions its safety and value under a great fever arff^M ' history of rheumatic many conditions that may arise folbw! teve (aiticular rheumatism), chorea, ing the birth of the placenta Two scarlatina, and other infectious diseases, noted obstetricians are giving it roT it?.!",.'' f'V'"'"^^"?""^ syphilitic tinely immediately upon the birth of d..sease may be discovered. the child; both have very large series ferenHJ'H?«c;;^!'''^^".V^^" ^°' *^" ^'^- "f '^'''' ^"^ ^' ^'^ have had no un- lerential diagnosis is the aopearance ot nleasant results, but until more has aortic stenosis a complication often ob-.heen done along this line definite con- served in endocardial aortic insufl^ici- elusions had better be reserved A ency. and only in exceptonal cases in number of onerators are administering- sypnilitics. r't,r-trm just as the uterus is beincr in- T T^ 7~^. " cised in cesarean section, or verv Large Doses of Tincture of Iodine in promptly after extraction of child, and RnnHr.«n f T ^J"""^^' , '"^^" sustained by ergot this procedure Boudreau, of Bourdeaux, several may be strongly indorsed. Some au- years ago recommeded large doses of thorities report fairly successful results tincture of iodine in the treatment of in the administration of pituitrin to aid 106 MISCELLANEOUS February, 1922. in the emptying of the bladder during the puerperum. When the cervix is fully dilated, when it can be accurately determined that there is no dispropor- tion between the passage and the pas- senger, when the presentation and po- sition are normal, when there are no obstructing tumors, and when the pains are weak and c'eclining we may be said to have ind'cations justifying the cau- tious use of small doses of pituitrin — 2 to 3 minims — remembering that epi- siotomy, or low forceps, or both, are usually better obstetrics. Contraindica- tions to the use of this drug are undi- lated cervix: disproportion between passenger and passage; abnormal pres- entation or position ; pressure of ob- structing tumors; scar from previous cesarean section or myomectomy; heart disease in the mother ; eclampsia ; threatened asphyxia of the child in utero; and when contractions are al- ready strong. If the above indications and contraindications are met, it is ob- vious that the administration of pitui- trin during labor at least will be ex- ceedingly infrequent. In conclusion a warning is sounded that he who admin- isters pituitrin to a patient in labor is using a very powerful and quick acting drug, whose strength is unknown and whose action upon the particular pa- tient can by no means be predicted, whose use has resulted in the prompt death of a large number of women, and a still larger number of children, and whose usefulness is limited to very nar- row fields. Cardiac Massage. Levy, in the Lancet, considers the term "massage" in this connection a misnomer and prefers the expression "mechanical stimulus." In the treat- ment of primary cardiac syncope from ventricular fibrillation cardiac massage finds its most urgent application. In animal experiments the writer has met with consistent success, but he ac- knowledges that in man the proposition is a somewhat different one, and that failures must be expected. He thinks, however, that with a proper knowledge of the principles involved and their careful application, very much better results might be obtained in cases of massage than has hitherto been the case. The rules for performance of car- diac massage in chloroform syncope are as follows : In syncope from overdosage, partial inversion and immediate artifi- cial respiration by the Sylvester method. If recovery does not occur in three min- utes, proceed to perform intrathoracic massage with perflation of the lungs. In syncope from primary cardiac syn- cope, partial inversion for two minutes. If SDontaneous recovery does not occur with'n two minutes, proceed at once to intrathoracic massage. In the interest of the nerve centers cardiac massage should be commenced within five min- utes. Success depends upon proper ac- cess to, and the efficient compression of both ventricles, and an efficient system of artificial respiration. If continued rhythmic compression is not successful in five minutes, it should be intermitted for periods of up to forty-five seconds' duration. Massage should be continued, if necessary, up to one hour's duration before abandoning the case. It is ad- visable to rely throughout on massage alone and discard the use of drugs. If the circulation is feeble after recovery, ?n intravenous injection of pituitrin is desirable. The Ice-Box Modification of the Wasser- mann Test. Keidel and Moore, in the Bulletin of Johns Hopkins, have examined by the ice-box method 300 cases in parallel se- ries with Wassermann tests performed according to original technique. The cases are divided into three groups on the basis of clinical diagnosis and pre- vious water-bath Wassermann tests. In the grouo of syphilitic cases 148 treated and 28 untreated cases are stud- ied. Greater sensitiveness was exhib- ited by the ice-box method in 50 per cent of this group, but the most strik- ing difference is seen in the greater per- sistence of positive reactions or some degree of fixation by this method in treated cases. In untreated cases this sensitiveness resulted in 10.7 per cent more positives, as compared with an in- crease of 37.8 per cent among treated cases. The plain extract in the ice-box gives more frequently complete fixation than cholesterinized antigen in the wa- ter-bath. Authors conclude that the study has ^^monstrated the superiority of the ' box modification in its selection of un- cured treated syphilitics. Its employ- ment for diagnosis is favored, but no positive results can be accepted without careful scrutiny of all available data in the case. February, 1922. MISCELLANEOUS 107 Ocular Manifestations of Syphilis. and invariably swear, when driven to Hereditary syphilis: (1) Early it, that everybody is mad, including- hereditary syphilis. Iritis is rare in the themselves, so that according to them infant and differs in no essential feature ^^'e really live in a mad world, from that in adults. More frequently It is quite manifest that this position met with at birth are posterior syn- is an untenable one, and we must seek aechia (irregular pupils). Malforma- better and moi'e practicable methods 'of lions of the ocular globe may be of dealing with criminals, syphilitic origin. Among the affections Some years ago, a poor old battered of infanthood there is one that points colored man called on me relative to particularly to syphilis, viz., glaucoma, training some horses of mine. I heard (2) Later hereditary syphilis. There is that he had wonderful success in thei practically only one manifestation, but management — and so I asked him how it is of capital importance, viz., inter- he succeeded so well, stitial keratitis. Lounging almost full length on an Acqured Syphilis. — Iritis is the com- easy chair, with a fine air of superi- monest syphilitic ocular manifestation, o^ity, he replied: "Doctor, it is most It is apt to supervene at the fifth or ^he same in my business as in your own, sixth month, or much earlier. Syphilis >'ou have to study the psychology- of the is by far the commonest cause of ocu- horse." lar paralysis — 60 per cent. Speaking This would apply with consummate generally, they are a late symptom ; they fitness to the suitable treatment of are grouped among the tertiary symn- criminals. toms. An aid to the diagnosis of syph- Of course, the Judge, who says to the ihs of nervous system is through exam- public, through his expression in court- ination of the pupils. Inequality of pu- "James, you should be whipped " has pils a presumption, not a proof of syph- opportunity to know all the particulars ihs; deformity of pupils caused by un- of the case and. in such possession of equal atrophy; myosis is a presumption facts, with a kindlv and honorable hu- of syphilis; Argj-le Robertson's sign man heart, would as a matter of pro- doss of pupillarv contraction to light, tection to the community, do as he it being retained on convergence) is a thinks would be a benefit to the corn- symptom of nervous syphilis belonging munity as well as to the criminal him- to the tabetic s^^ries. but it alone does self. not justify the diagnosis of tabes. Mr. Philanthropist, in his magazine, raises his pious hands to heaven and Q 4u t» J scores the Judge for expressing such impure the Kod. blood curdling sentiments, and the pious C. F. Buckley, in the Medical Senti- parson in the neighboring church re- nel, reminds us that for ages past the echoes the .same idea, until the rafters subject of criminals and their proper ring out with imprecations on the blood- treatment has been a theme for specu- thirsty villain who proposed those sen- lative philosophers, writers and think- timents- ^^^- The Philanthropist is crowned with _ Not over a century ago the poor luna- laurel wreaths and big subscriptions. tic was regarded as a criminal and For thoughtless men and women it treated accordingly, until Dr. Connolly requires no elaborate reasoning to show ot London said that he could accom- which of those two men is the greater plish more by kindness in most cases. benefactor of humankind. He put his theories to the test and The Judge has no personal feelings in succeeded instanter, so that his name this matter, and seeks no vengeance; stands out today conspicuously as one he simply wants to protect the people of the great benefactors of humanity. against savagery. th^nLr^^Pl«n1f^^i.w!^,^ ^^^^^ ""^""^ ^* '^ P"^"^^ nonsense in this connec- sKh hp ivt l}^^^^^^ the same method tion to ring in the pillory and the fagot, fhpv .1. '^.^n^Ti"''^.^'^^'^^"^^ ^^^ these brutalities have passed and they also are mentally defective. never can return, unless we drift back inis is on a par with the views of so into savagery frfrf/o °^ ^hT^ ^fdical gentlemen, who Time was when the bold highway- appear on the witness stand as experts man became a popular idol, and it looks 108 SOUTHERN MEDICINE AND SURGERY February, 1922. Table of Contents for February, 1922 Original Communications Cancer of the Lip and Buccal, Mucous Membrane, by William D and A. W. James, M. D. 57 Focal Infection, by R. E. Lee, M. D 58 Puerperal Septicaemia, by Parran Jarboe, M. D. 61 Surgical Judgment in Operation on the Nose, by Louis Nelson West, M. D 63 Paroxysmal Tachycardia, by J. Morrison Hutcheson, M. D. 65 Primary Sarcoma of the Appendix, by Hy- man L. Goldstein. M. D 68 Neosalvarsan in Yaws, by Louis E. Jag- gard, M. D. '^2 Errors of Refraction— Etiology and Treat- ment, by Dr. O. J. Houser, M. D 73 The Mechanism and Management of the Third Sla^e of Labor, by Ivan Proctor, M. D. _--° "^ Doctors and Dreams "^8 Editorials. lodin and Goiter 79 How Physicians Die 80 Automobile Fatalities 80 Polyvalent Vaccine-Therapy in Cholecys- titis 81 The Referendum on Alcohol 81 Department Editors. Gvnecologv and Obstetrics, Robert E. Sei- bels, M. D. 83 Urology, A. J. Crowell, M. D 83 Mental and Nervous, James K. Hall, M. D. 85 Pediatrics, Yates Faison, M. D 87 State Medicine, L. B. McBrayer, M. D 88 Orthopaedics, Alonzo Myers, M. D 90 Roentgenology, Robt. H. Lafferty, M. D 91 Hospital and Sanatorium, John Q. Myers. M. D. 91 Publications Received 92 News Items 93 Miscellaneous 101 very rnich as though his represGnta- tives, the hold-up man and train robber and other such, were again on the eve of acquiring the glamor of their proto- types, and be glorified by the thought- less people of the world. To those who think, it is quite evident that this hardihood and daring in crime is not acquired in a day, a week, or a month ; but is the fruit of the degrading culture surrounding for some length of time previously. Will a boy of high spirit, who hears nothing but extolation and laudation of the achievements of this class, be deter- red by religion, by culture, or by any advices, from following the bright ex- amples, as they consider it, of this class ? Moral suasion has no influents in curbing this vicious ambition. H.? soon makes some false step, which gets him into the clutches of the law. He is sent to the reformatory, and there his life is very little diflferent from what it has been outside. He has just about as good things to eat, and as much creature comforts as he previously had, and he very reasonably argues that there is na punishment in this. He then takes a bolder flight, and goes over the same road into the peni- tentiary, and repeats his industry until he becomes a candidate for the rope or the electric chair. I assert, without fear of successful contradiction, that if this boy had been taken after his first lapse, and been treated to a few well delivered lashes, he would not have been so ready to cempt fate again in violating the law. Southern Medicine and Surgery Vol. LXXXIV CHARLOTTE, N. C, MARCH, 1922 No. 3 Registration at Norfolk Meeting, February, 1922 C. Banks McNairy Kinston, N. C. P. C. Rinker Norfolk, Va. A. E. Baker Charleston, S. C. A. B. Patterson Barnwell, S. C. L. A. Crowell-.. Lincolnton, N. C. F. H. McLeofl Florence, S. C. John H. Miller .Cross Hill, S. C. W. B. Ward Rock Hill, S. C. M. L. Townsend Charlotte, N. C. H. R. Black Spartanburg, S. C. Henry A. Christian Boston, Mass. Warren T. Vaughan Richmond, Va. W. H. Dixon Ayden, N. C. R. E. Hughes Laurens, S. C. Chas. S. White Washington. D. C. A. R. Shands Washington, D. C. ■Jas. W. Gibbon Charlotte. N. C. Fran't D Worthington... Charlotte. N. C. Addison C Brenizer Charlotte. N. C. Tom A. Williams Washington, D. C. D. A. Stanton High Point, N. C. James C. Doughty Onancock, Va. L. Humphreys Norfolk, Va. F. F. Williams, Jr Richmond, Va. L. L. Williams, Jr Richmond, Va. I. P. Battle Rocky Mount, N. C. A. J. Crowell Charlotte, N. C. H. Page Mauck Richmond, Va. Seavy Highsmith Fayetteville, N. C. Chas. L. Summers Baltimore, Md. James H. Mcintosh Columbia, S. C. W. P. Timmermann Batesburg, S. C. Fred M. Hodges Richmond. Va. R. H. Wright Richmond, Va. Jos. T. McKinney Roanoke, Va. K. D. Graves Roanoke, Va. Chas. O'H. Laughinghouse_Greenville, N. C. Karl S. Blackwell Richmond, Va. F. S. Johns Richmond, Va. Cyrus Thompson Jacksonville, N. C. A. P. Jones Roanoke, Va. S. S. Gale Roanoke, Va. John O. Boyd Roanoke, Va. M. Eugene Street Glendon, N. C. Everette E. Watson Salem. Va. Fred H. Albee New York, N. Y. Louis E. Bisch Asheville, N. C. J. Y. Templeton Portsmouth, Va. R. Finley Gayle. Jr Richmond, Va. Jos. F. Geisinger Richmond, Va. W. E. Anderson Farmville, Va. John B. Ray Leaksville, N. C. R. D. Glasser Norfolk. Va. E. M. Gayle Portsmouth. Va. J. H. Harper Snow Hill, N. C. Joseph Bear Richmond. Va. J. Howell Way i-Waynesville, N. C. D. T. Tayloe Washington, N. C. D. T. Tayloe. Jr Washington, N. C. J. T. Burrus High Point. N. C. H. A. Inman Norfolk, Va. Jas. W. Vernon Morganton, N. C. J. W. Long Greensboro, N. C. Z. G. Smith Marion, S. C. John B. Deaver... Philadelphia, Pa. Stanley H. Graves Norfolk, Va. John P. Kennedy Charlotte, N. C. Geo. H. Bunch Columbia, S. C. Wm. R. Barron Columbia, S. C. Hamilton W. McKay Charlotte, N. C. H. C. Shirley Charlotte, N. C. W. W. Silvester Norfolk, Va. J. Gates Goode Cheriton, Va. J. C. King Radford, Va. R. L. Pittman Fayetteville, N. C. R. B. Epting Greenwood. S. C. G. A. Neuffer Abbeville. S. C. Davis Furman Greenville. S. C. C. J. Riddick Suffolk, Va. N. Thos. Ennett Richmond. Va. W. V. Crosby Norfolk, Va. Brodie C. Nalle Charlotte, N. C. Alonzo Myers Charlotte. N. C. M. Katzoff Norfolk. Va. W. A. Shepherd Richmond. Va. D. C. Smith University. Va. Stuart McGuire Richmond, Va. Guy R. Harrison Richmond. Va. A. L. Gray Richmond, Va. W. L. Peple Richmond, Va. J. F. McKay Buies Creek, N. C. Robert C. Bryan Richmond, Va. Chas. V. Carrington Richmond, Va. Stephen Harnsberger Warrenton. Va. W. F. Merchant Manassas. Va. Garnett Nelson Richmond, Va. E. M. Chitwood Wytheville, Va. G. M. Brooks ___Elm City, N. C. 110 SOUTHERN MEDICINE AND SURGERY March, 1922. C. T. Smith Rocky Mount, N. C. J. C. Cuttle Newport News, Va. David May St. Louis, Mo. L. G. Gage Charlotte, N. C. E. T. Dickinson Wilson, N. C. A. Fields Norfolk, Va. E. M. Townsend Norfolk, Va. J. M. Simpkin Norfolk, Va. J. R. Parker Burlington, N. C. G. Bentley Byrd Norfolk, Va. Major I. Fleming Rocky Mount, N. C. Walter J. Adams Norfolk, Va. E. S. Boice Rocky Mount, N. C. Paul W. Howie Richmond, Va. J. A. Lipmich Norfolk, Va. Jas. W. Weston Norfolk, Va. W. E. Driver Norfolk, Va. J. H. Royster Richmond, Va. Jas. K. Hall Richmond, Va. Southgate Leigh Norfolk, Va. Jas. W. Hunter, Jr Norfolk, Va. J. Morrison Hutcheson Richmond, Va. Lawrence T. Price Richmond, Va. J. Allison Hodges Richmond, Va. E. H. Terrell Richmond, Va. C. C. Coleman Richmond, Va. Dr. Royster Norfolk, Va. J. H. Branan Hampton, Va. J. L. Lister Jackson, N. C. P. G. Parker Jackson, N. C. W. T. Potter Ocean View, Va. G. H. Summerell Ayden, N. C. A. D. Owenbey Newport News, Va. Chas. A. Saunders Norfolk, Va. H. Harrison Norfolk, Va. A. A. Burke Norfolk, Va. J. E. Rawls Suffolk, Va. Thos. W. Murrell Richmond, Va. E. C. S. Taliaferro Norfolk, Va. W. Wallace Gill Richmond, Va. Ivan Proctor Raleigh, N. C. J. E. Delhi Norfolk, Va. P. G. Hamlin Williamsburg, Va. J. B. Ruffin Powellsville, N. C. Chas. J. Sawyer Windsor, N. C. Beverley R. Tucker Richmond, Va. Jas. H. Culpepper Norfolk, Va. N. Bruce Edgerton Columbia, S. C. Clifton M. Miller Richmond, Va. L W. Costen Suffolk, Va. B. L. Carleton Newport News, Va. Sidney J. Tabor Portsmouth, Va. M. S. Bulla -Elizabeth City, N. C. C. B. Williams Elizabeth City, N. C. J. W. White Norfolk, Va. Lewis Berlin Norfolk, Va. Members Elected at Norfolk Meeting of the Tri-State, February 22-23, 1922 Dr. Wm. Rowan Barron. -Columbia, S. C. Dr. Geo. Martin Brooks_-_Elm City, N. C. Dr. Mora S. Bulla Elizabeth City, N. C. Dr. Benj. L. Carleton Newport News, Va. Dr. Edmund M. Chitwood.Wytheville, Va. Dr. Arthur W. Deans Battleboro, N. C. Dr. W. H. Dixon Ayden. N. C. Dr. Major T. Fleming Rocky Mount, N. C. Dr. William Franxton Charleston, S. C. Dr. Jas. W. Gibbon Charlotte, N. C. Dr. P. G. Hamlin Williamsburg, Va. Dr. Jas. H. Harper Snow Hill, N. C. Dr. J. S. Horsley Richmond, Va. Dr. William D. James Hamlet, N. C. Dr. John Wesley Long.-- Greensboro, N. C. Dr. Lawrence E. McDaniel-Tasker, N. C. Dr. H. B. Marriott Battleboro, N. C. Dr. Ivan M. Proctor Raleigh, N. C. Dr. Jas. J. Ravenel Charleston, S. C. Dr. Jas. H. Royster Richmond, Va. Dr. H. C. Shirley Charlotte, N. C. Dr. C. T. Smith Rocky Mount, N. C. Dr. J. A. Strickland Norfolk, Va. Dr. Cyrus Thompson Jacksonville, N. C. Dr. Milton Weiberg Sumter, S. C. Dr. L. L. Williams Richmond, Va. Dr. H. H. Wescott Melfa, Va. Dr. Frank D. Worthington- Charlotte, N. C. a ^ .5 -g I 3 C M 05 ^ O ^ s ^ « -So o ag 2^ M O o o o o o u 1^ ^ ^ ^ cc m (D (D 6 (U I . re • 2 ® ^U o 2 ■ S tog 5 - *> ?S.S 2.62 « ^ ^' < a _g ffi u ^' SC I ^ ^ J u 1 o -,«• 6^ -32 > ' £f > ^ 3 o hccc r O O 1"! >^ "33 ^ ^ PS a W) ■fi - 9 5 = 1 §5 6 I o ~> -J a; o = ^- O 0) t; ni o aJ a; E- iS D '=« • X M) , S' ^ W 5 u > .02 (3^3 O 3 ^ III - ,r. ^ d g =« ?3 ^ s PQ M g a> ;<3 0^ d << ^ K J -.; I ^ ;^' tf 2S^ .S to <: .a n.2r 1^^ ;>* ,H r: !- X X X X X K K X K a a H a a a a a a O 00 » _j ^ ^ (U fc.' 4) S ? *=* 2 rt 02 .M ^ fl H S^ » II JS o 1^- w offi >> t: «J S;P !tS O "O O aa S « o ii >. cS rt o ^ « C^^ ^ ^ o ; C ! ou '^ai go >|d I^E So oQ « (In fl ag-S d « ;S o r o c PS"- Sai-i S,X o 03 K ^ .- OJ 21 o >^ .CQ = S| ■ d g to O f*' oj .22 . i-s "to ffi ° c .. ^dd g U be ■s .9 3 Ui^X c •r S. S. GALE, U. D., Roanoke, Va. President Elect for 1923 Meeting 114 SOUTHERN MEDICINE AND SURGERY March, 1922. TRANSACTIONS OF THE TWENTY- to be here. He has, however, requested FOTTRTH ANNIT4T SFSSTON OF the Hon. R. W. Peatross, City Attorney, FOURTH ANNUAL SbbMOJN Vt ^^ resent him. I take pleasure in THE TRI-STATE MEDICAL ASSO- introducing Mr. Peatross. CIATION OF THE CAROLINAS Hon. R. W. Peatross, City Attorney AND VIRGINIA, NORFOLK, VA. Mr. Chairman, Gentlemen of the REPORTI1.K. ^^^^ ^jjj ^^ ^g^y g^^^^ ^j^^^ ^g ^jjj ^^^g Opening Exercises, Wednesday, Febru- our new municipal auditorium, in order ary 22, 10 A. M. that we may extend to you our hospital- , . ' * il , . J ^ ity in that magnificent style to which The Association was called to order ^^^^ profession and charms entitle you. by Dr. Southgate Leigh, Chairman ol j^^ ^^^ meantime, we are looking after the Committee of Arrangements : ^^^ ^^ ^-^e best way that we can and try- Dr. Southgate Leigh ing to hand out our hospitality with a As Chairman of the Committee of Ar- liberal hand, rangements it is my very pleasant duty ^^ Today we are a little bit overcrowded, to cill together the Twenty-Fourth An- We are like the old lady who said, nual Session of the Tri-State Medical "Seems like I have got more visitors Association. The proceedings will be than I is chairs, and Lord knows I got opened by prayer by the Right Rever- chairs enough. We have the Legisla- end Beverley D. Tucker, Bishop of ture, the Governor and his staff and we Q^ ^-l,«^v, v,v.r,-«io have the automobile show going on m Southern Virginia. ^^^^^ ^^^ ^^ ^^^^ ^^^ gentlemen, but The Right Reverend Beverley D. Tucker, we are going to do the best we can to Bishop of Southern Virginia make you feel at home. The difficulty Oh, our Mighty God and Blessed Son, is that with all these things going on Jesus Christ, the good physician both the crop of orators has played out. In to the bodies and souls of men, grant to the old days the newspapers referred to these thy servants to be partakers of Kansas as "bleeding Kansas." Some- His holy ministry. Help them to relieve body asked Will Allen White, "What is human [suffering. In their high and the trouble with Kansas?" He said, holy calling may they be followers of "There ain't but one trouble in Kansas. Him who bore our sicknesses, and in Kansas started out to raise hell and got all our afflictions was afflicted. We ask an over-production." it in the name of Him to whom be all Our orators have played out. The honor and glory forever and forever mayor told me he was so anxious that jnore. the municipal government should pay "Our Father which art in heaven, tribute to you gentlemen, should greet hallowed be thy name. Thy kingdom you. should extend to you the hospital- come. Thy will be done in earth, as it ity of our city, that he asked me, as his is in heaven. Give us this day our daily personal representative, to come here bread. And forgive us our debts, as we and say to you that Norfolk appreciates forgive our debtors. And lead us not your coming, that he believes your com- into temptation, but deliver us from mg will do us good, and we hope that evil : For Thine is the kingdom, and you can use us. the power and the glory, forever." • William McKinley, when President, The grace of our Lord Jesus Christ, "^ade an address at the Buffalo Exposi- the love of God, the fellowship of the tion on the day that he was stricken Holy Ghost be with us all forever more, ^^wn by the assassin's bullet, which he Amen. began with these words : "Expositions and conventions are the milestones on Dr. Southgate Leigh the road of progress." I believe that is The Hon. A. L. Roper, Mayor of Nor- particularly true of a gathering of this folk, requested me to state to you that character, a gathering of you medical on account of the fact that the Legis- men. lature visits Norfolk today he was An old doctor was talking to me once, obliged to go over to Newport News to and this was long before the germ meet them, and that he will not be able theory started, He explained to me how March, 1922. ORIGINAL COMMUNICATIONS 115 the germ theory was beginning. He which you bring will be disseminated said somebody will get a line on some- and diffused among us, and even by the thing that will give him an idea that a process of absorption some of it will be theory can be worked up, and somebody appropriated by us and become a part over here gets another idea, and we get of our own. Not only will your tech- together in conventions, put our heads nical knowledge be of value to us, but together and find that two and two make your presence is an inspiration which four. Then we build up a whole sys- will encourage us in our endeavor to tem of theories which result in great solve the problems of the city. Perhaps benefit to mankind. It is by the attri- not the smallest part of this meeting, so tion of ideas that strikes the spark far as we are concerned, is the fact that which lights the lamp of progress. it gives us an opportunity of coming in You gentlemen, whose lives are de- personal contact, not only with old voted to the relief of the stricken and friends, but with so many men whose the helping of suffering humanity, when purposes and aims are the same as our you gather together and give to each own. other the benefit of wise counsel, of your I am aware of the fact that the prin- good judgment, and your deep study are cipal purpose of your presence here is adding to the sum total of the world's related to work, for I know that your knowledge, not only of the provincial own committee has arranged a program knowledge but of the world knowledge, of knowledge, interesting and excellent, and increasing human life. but I trust you will not be entirely oc- We are gratified that you have come cupied by this and that you may enjoy to our city. We want you to feel that the diversions which have been planned. Norfolk is yours while here. Under the I hope that this may give you at least a law you can write your own prescrip- fraction of the pleasure that it gives tions. If the druggists can't fill them, those who prepared them. Gentlemen, why I am pretty well assured that the I welcome you. head of the Health Department of Nor- folk has a right good article of medi- Response, Dr. F. H. McLeod cme down there. He ought to have, be- cause he got it sometime ago and no- ^^- Chairman, members of the Tri- body has been able to get it away from State Medical Association : It is quite him. If you find we have too many embarrassing that our President should ordinances here and they interfere with ^^ detained by illness, and that our ora- your pleasure, we want you to feel ^^^ ^^^ "^t been able to get here. I have while you are here that you are citizens "^^ heard from him, I know that some of Norfolk, and we don't hesitate to ^^^^ serious disaster has happened be- break them. cause Dr. Lander is a real orator, and, We give you the keys of the city and doubtless, has prepared something for welcome you into our midst, and pray "^ ^^^^ ^'^^^ please the gentlemen for the very highest blessings of prog- ^^^atly. On behalf of the Tri-State ress to rest upon you as you work for Medical Association we thank you for the blessings of mankind. your most cordial welcome. I trust all of you have taken notice Address of Welcome on Behalf of the ^^ ^^^ city attorney's very open sug- Norfolk County Medical Society Dr. gestion and have brought your prescrip- C. J. Andrews, President of the Nor- ^^on blanks. I am satisfied from what folk County Medical Society he has said there will be no difficulty in Mr. Chairman, Members of the Tri- ^^"!,"^ *^^^ ^"^t • > . m . n r State Medical Society, Invited Guests, ^^'^ '^ ""^ ^^^^ ^'^'* ^^ Norfolk. I Ladies and Gentlemen : It is my pleas- ^^^^ missed the other meetings here, to ure in the name of the Norfolk Cunty my great regret, and all of the men who J^f.^^^^riu^^^^^^^ *^ welcome you to Nor- have told me of these wonderful meet- S-So"ietyT'Sfortlt?H^|l^^!fs1[ !",- ""^ ,^-" - enthusiastic about does so many distinguished meA and ^^^'"^ reception and fine treatment that workers in various fields, gives us a ^ ^^^^ forward with great pleasure to distinct sense of gain. The abundant what we will receive and am sure we store of knowledge and experience will not be disapponted. 116 SOUTHERN MEDICINE AND SURGERY March, 1922. Dr. Southgate Leigh uled, and we are going to expect that Dr. Fennell, our President, is detain- each paper be read. within the 20 minute ed by illness, and I am sure it will be time limit, as announced under Intor- a great distress to all of us. The doc- mation" at the back of program, tor was here a few days ago with Dr. ^j. j^ ^ L^^g^ Greensboro Hall looking after the arrangements of the meetings. He was taken sick just I want to introduce this resolution: after going home. In his absence Dr. "Whereas: The Tri-State Medical H. R. Black, Vice-President from South Association, having learned of the seri- Carolina, will preside over the meetings, ous illness of its President, Dr. W. W. It gives me great pleasure to introduce Fennell, Rock Hill, S. C, Resolves : to you your presiding officer. Dr. Black. pj^st : That the Association extend Dr. H. R. Black its condolence to Dr. Fennell and pray for his speedy recovery, n. ^o- P^i''"?-^''i \"^ Members of the ^^^^^^ . rj.^^^ ^^e Association hereby Tri-State Medical Association, Visitmg expresses its utmost confidence in Dr. Doctors, Ladies and Gentlemen: I re- pgnnell and admiration for his contri- gret very much the absence of Dr Fen- ^utions to surgery. nell, and I know that you do. I did not ^, . . . rp, , , • . President know until Monday past that the doctor . -^^^^^ • J^^l his work as president was sick, therefore, this duty thrust m preparation for this meetmg is much upon me was very much unexpected, appreciated and his absence greatly re- and very much without any preparation. S^^ttea. Dr. Fennell's family called me over the Fourth : That the Secretary be au- phone Monday, and I also received a thorized to wire these resolutions to wire from Dr. Hall stating that I would Dr. Fennell." be expected to preside over this meet- It is moved by Dr. R. E. Hughes that ing. Now, gentlemen, I earnestly desire these resolutions be adopted, your hearty co-operation. With Virginia, This motion is seconded and carried. North Carolina and South Carolina be- n jg moved by Dr. Warren T. hind me to support me, with our visit- Vaughan, Richmond, Va.,' that all visit- ing doctors I am sure we will do the jng physicians and surgeons be invited very best that we can. to participate in the discussions. Dr. Southgate Leigh This is seconded and carried, I urge every member to register ^^,^ ^^^^^^/^ ^^^n proceeded to the promptly and every lady to register ^^^"^^^ scientific program. promptly. I should like to say a word about the entertainment. Tonight the Thursday Afternoon, February 23rd committee has provided an entertain- in *• # nfti ment at the Country Club, several miles ^^^^^^^^ «^ ^^^'^'^ distant, and automobiles will be parked Dr. H. R. Black in front of the main entrance of the The election of officers is in order. Monticello Hotel to carry the members The chair is ready to entertain a motion and guests and ladies down to this en- of nomination of President: tertainment. We will go immediately ^ ^ t^ r^ , „. . from this hall on adjournment to the ^^' ^' ^- Tucker, Richmond Monticello and take automibles for the It gives me great pleasure to place Country Club. I would like each one before the house the name of a gentle- of you to provide yourselves with tick- n^an from our state for the nomination ets to be shown at the door. Tickets for President of this Association, This will be provided for out-of-town mem- has grown to be a great Association, bers and ladies from this desk here. The which all of us have close to our hearts, reception committee will be at your ser- I feel that in placing the name of Dr, vices at all times, S, S. Gale before the house for Presi- Dr H R Black ^^"^ ^^ would make no mistake. Dr. * ' Gale has been a successful practitioner We have a fairly lengthy program, and has built up a successful institu- These meetings are going to be called tion. He is at present and has been for to order promptly on the time sched- a number of years Vice-President of the March, 1922. SOUTHERN MEDICINE AND SURGERY 117 Norfolk & Western Railroad. He is active, intelligent and energetic. I feel that the Society can't do a better thing than to elect Dr. S. S. Gale as its Presi- dent. I do not feel that it is necessary to make a speech with fulsome laudations. I feel we all know Dr. Gale and I have no hesitancy in submitting his name to this body. Dr. Southoate Leigh, Norfolk, Va. I want to second the nomination of Dr. Gale. Dr. F. H. McLead I also second the nomination of Dr. Gale. Dr. A. L. Gray, Richmond, Va. I second the nomination of Dr. Gale and move that the nomination be closed. Dr. Southgate Leigh, Norfolk, Va. I move that the Secretary cast the ballot of the Association for Dr. S. S. Gale. Dr. H. R. Black Dr. S. S. Gale is unanimously elected. The next nomination in order is nomi- nation of Vice-President from South Carolina. Dr. F. H. McLeod I nominate Dr. W. P. Timmerman. Dr. W. P. Timmerman I have served as Vice-President of this Association. I appreciate the com- pliment to me, but feel I should not be elected again. Dr. A. E. Baker I nominate Dr. F. H. McLeod. Dr. F. H. McLeod I have served as Vice-President of this Association. Dr. W. P. Timmerman I nominate Dr. R. B. Epting of Greenwood, S. C. Dr. Southgate Leigh I move the nomination be closed and that the Secretary be instructed to cast the vote. This motion seconded and car- ried. Dr. J. T. Burrus If I were to tell you all the good things that I have to say about a gen- tleman I hope you will elect as Vice- President from North Carolina I would keep you for many hours. I shall not. It is enough for me to say that he is a learned doctor and wise surgeon, and he is a most profound gentleman. He is faithful, and has been for many years, to the Tri-State Medical Association — Dr. L. A. Crowell, of Lincolnton, N. C. This nomination is seconded. Dr. Cyrus Thompson, Jacksonville, N. C. Dr. Crowell is my friend. I think a very great deal of him, and if we had two Vice-Presidencies for North Caro- lina I should be after giving him one of them. I had in mind, not knowing he would be put in nomination, to nominate for the Vice-Presidency of North Carolina, Dr. Ivan P. Battle, of Rocky Mount, N. C. He is not a group practioner and he is not a surgeon. He is much young- er and, therefore, less wearisome than I could be. He belongs to the great and waning class of general practitioners. He is a young man, in the prime of his life, and, yet, old enough to be mature in wisdom. He comes of proud North Carolina stock. His ancestry — the orig- inal one of them, must have been a great fighter, because he got fixed on him and can't get rid of it, even in a peaceable county like Edgecombe county. North Carolina, that Irish sort of name "Bat- tle"— all the time battling. I should be pleased with the election of either one of them, but at this time I would like to see my man get it, rather than the other man, and I will be for the other man some other time. Dr. L. A. Crowell I was elected Vice-President of the Association in Charleston, S. C. I with- draw my nomination. Dr. Cyrus Thompson That reminds me of that ancient play, "After you, my dear Gaston, after you !" Dr. E. T. Dickinson I second the nomination of Dr. Battle. Dr. J. T. Burrus Since Dr. Crowell wishes it, I delight in complying with his request and with- draw Dr. Crowell's name. I am so sure that when my friend Cy Thompson starts anything that it is always right, 118 SOUTHERN MEDICINE AND SURGERY Inarch, 1922. and because I have seen him in many Dr. J. T. Burrus, High Point, N. C. and varjing stands with varying pres- Before the report of the Council is sure brought to bear, I want to second delivered to this body I want to extend the nomination of Dr. Battle. this Society an invitation to meet in a T^ r» A 04 * u- u ij • 4 M r city in North Carolina that has grown Dr. D. A. Stanton, High Point, N. C, .^ ^^ ^^^ ^^^^^ ^^^^ ^ ^^^^ ^^^U ^.^_ moves nomination be closed. This mo- j^^^ ^^ ^ ^^^n that you are all familiar tion is seconded. ^j^h. Coming with this invitation I am It is moved that the Secertary cast instructed by the Kiwanis Club, the the vote of the Society for Dr. Battle. Rotary Club, the Manufacturers Club, Dr. J. A. Hodges, Richmond, Va. ^jd the Commercial Club, and every ^,,. ^ . ' ,-u physician in town and county to extend I believe I voice a very general wish ^^ ^^-^ organization a desire that you among the Virginia profession m nom- ^^^^ -^ ^-^^ ^^-^^ North Carolina, mating Dr. W. E. Driver of this city as ^^^^ ^^^ Vice-President of this state. Dr. Driver ^e have there an elegant new hotel, IS a specia ist, but he has always taken ^^^ ^^^^^ ^^ ^^o have visited this a very noble interest m the general sci- hostelry since it has been opened will ence of surgery and medicine, and I re- ^^^^ ^^ ^^^ j^ ^his statement that there call his very meritorious work in ma- jg ^^ ^g^ter hotel in North Carolina laria several years ago, and I am sure ^^an this. We want you in High Point that his election will give great satis- ^ext year, and if you come to us we taction. assure you that everything that we can Dr. W. E. Anderson do will be done for your pleasure and 3eh second On behalf of Virginia I very heartily for your entertainment. 1 the nomination of Dr. Driver. , ^ow, I want to say just here that I T^ . J , J 1 ^, X ii. shall not promise you a great big fine It IS moved and seconded that the country club nor the elaborate enter- nommation be closed. tainment that the chairman of your It IS moved and seconded that the committee was able to deliver to us, and nomination be made unanimous. This I am not just sure how the Volstead motion carried. Act is going to apply at the time, but we Dr. H. R. Black ^^"^ ^°" ^"d we will do the best we rr-u i. * • -L-* • J • J.1 i. can for you, and I hope you will come The next nomination in order is that ^j^^ us of Secretary-Treasurer. Dr. J. T. Burrus, High Point, N. C. ?■■• ^- ''• f ""'!!'• Charlotte N. C. Now is no time to change the office ^ "°™ ""= '"'™ "'<' Secretary's report. of Secretary and Treasurer. I move Dr. J. K. Hall, Richmond, Va. that Dr. James K. Hall be made Secre- Mr. President : At the meeting of tary of this Association. the Executive Council last night in pur- Dr ^nllf hp-afP T Pio-h suance of its established custom three Dr. Southgate Leigh vacancies in the Council were filled. The nomination is seconded and These elections last for the three-year bears tribute to the wonderful work he period. The elections to the Council has done, especially m getting up this were as follows : For the state of South ""T^ • ^' ^ .1, ^ .u • .• u Carolina, Dr. George H. Bunch, Colum- It is moved that the nomination be bia. For North Carolina, Dr. J. W. ^^^^^"- Long, of Greensboro. For the State Dr. A. J. Crowell, Charlotte, N. C. ^^ Virginia, Dr. F. C. Rinker, of Nor- It is moved that the President cast ^^^^' the vote for the Secretary. ^^ was the unanimous opinion of the Council that the same arrangements Dr. H. R. Black that exist with Southern Medicine and I take pleasure in casting the vote for Surgery for the publication of the pro- the re-election of Dr. Hall. ceedings of the Tri-State Medical Asso- Ttr A T r».«w^ii rv.o^i^44 XT r- ciation be continued throughout the Dr. A. J Crowell, Charlotte, N. C. year. It publishes the papers and dis- the next thing is the report of the cussions and transactions, and a copy ^^""cil. of Southern Medicine and Surgery is March, 1922. ORIGINAL COMMUNICATIONS 119 sent to each member of the Tri-State Med'cal Association for the sum of $1.50 a year, and this subscription is paid for by the Tri-State Medical Asso- ciation Treasurer. If the members of this Association do not get that journal thev should notify the Secretary of that fact. Dr. D. A. Stanton of High Point, N. C, appeared before the Council and extended in his own name and in the name of numerous organizations of High Point a very cordial invitation to the Association to meet next February in High Point, N. C. The Secretary u'ould like to report as Treasurer that the Tri-State Medical Association, which two years ago, was about $1,300 in debt, is now about out of debt. I think it is out of debt, but I have to add this, the transactions of the meeting of 1920 held in Charlotte have not yet been published, and the Council authorized the Treasurer to hold on to these transactions until in the judgment of the Treasurer he feels that the Asso- ciation is able to pay for the publication of the transactions. I hope that before we meet in High Point that these trans- actions will be in the hands of all of you in book form. Dr. A. J. Crowell The Council recommended that we go to High Point. Dr. James K. Hall, Richmond, Va. The Secretary forgot to announce for the Council Body that the Tri-State Medical Association had a very cordial invitation, an exceedingly pressing and cordial invitation to meet next year in Winston-Salem. N. C, another to meet in Charlotte, N. C, and the Secretary had a personal communication from Mr. Leonard Tufts begging us to meet in Pinehurst. Dr. A. J. Crowell It is moved that the Association adopt the suggestion of the Council and ac- cept the invitation to High Point. Dr. W. E. Anderson I move we leave that to the Executive Committee. With so many invitations it is quite worth while to consider care- fully all of them, so I move that it be left with the Executive Committee. Dr. James K. Hall, Richmond, Va. The Secretary states that at the meeting of the Council that the Council was in favor of accepting the invitation to meet next year in High Point, and decided to make that recommendation to the open house. The Secretary ought to state that last year at Spartanburg the Tri-State in- creased its membership 57. This year it has increased its membership 20-odd and they are still joining. Dr. Cyrus Thompson We ought to decide definitely where to go. There is no better place to go than High Point. It is a furniture town. You can sit down all you want to for they have plenty of chairs. You can lie down when you want to for they have plenty of beds. If there is no club house there we can drive down to Greensboro or over to Thomasville. I think we ought to settle it. Dr. W. P. Timmerman I move we adopt the report of the Executive Council. The report is voted on and adopted. Dr. W. L. Peole We have all had a very delightful time here, and to show that we feel deeply grateful to the management for arrang- ing everything so beautifully I am go- ing to offer the following resolution : The Tri-State Medical Society, through its Secretary, wishes to thank the various organizations and commit- tees for their most cordial reception and dellightful entertainment of our So- ciety. Among these are: The Chamber of Commerce, Board of Trade, The Norfolk County Medical Society, The Navy Y. M. C. A., the newspapers, Mr. Otto Wells, who so kindly furnished us with a stereopticon and an operator, the management of the Monticello Hotel, and lastly, but not least, the committee for the entertainment of visiting ladies and for the charming entertainment at the Country Club last evening. It is moved, seconded and carried that this resolution be adopted. 120 SOUTHERN MEDICINE AND SURXIERY March, 1922. Transactions of the Meeting of the Ex- Presidents Society of the Tri-State Medical Association, February 22, 1922. At the annual dinner given to the Ex- Presidents of the Tri-State Medical As- sociation by those members residing in the state in which the meeting was held the following gentlemen were present: Dr. A. E. Baker, Charleston, S. C; Dr. Dave Tayloe, Washington, N. C; Dr. J. Howell Way, Waynesville, N. C. ; Dr. R. E. Hughes, Laurens, S. C. ; Dr. Stuart McGuire, Richmond, Va. ; Dr. Davis Furman, Greenville, S. C; Dr. J. Alli- son Hodges, Richmond, Va.; Dr. South- gate Leigh, Norfolk, Va. ; Dr. J. H. Mc- intosh, Columbia, S. C; Dr. Robert C. Bryan, Richmond, Va. It was moved by Dr. Furman and seconded by Dr. Baker that Dr. McGuire be re-elected president of this society. Motion carried. It was moved by Dr. Hughes and sec- onded by Dr. Baker that Dr. Bryan con- tinue as secretary of the society. Mo- tion carried. It was moved by Dr. Hodges and sec- onded by Dr. Hughes that a telegram be sent to Dr. Fennell, President of the Tri-State Medical Association, express- ing the sympathy of this body at his en- forced absence, due to illness and the wishes of an early convalescence. The President instructed the Secretary to send this telegram, which was done. Dr. Hodges moved that a committee of three, representing the three states constituting the Tri-State Medical As- sociation, be appointed by the President to look into the feasibility of investi- gating a move to make the meetings of the society more individual and attrac- tive so that some feature would be asso- ciated with the society for mutual ben- efit. This motion was carried. The chair appointed Dr. Hodges of Rich- mond, Dr. Way of Waynesville and Dr. Hughes of Laurens to serve on this com- mittee and to report their recommenda- tions at the next meeting in High Point, N. C. Dr. Leigh was requested to send a statement of the dinner expenses to those members of the society from Vir- ginia who were present, Drs. McGuire, Hodges and Bryan. There being no further business the meeting adjourned. THE VALUE OF HEAT IN THE TREATMENT OF CANCER- By W. W. Fennell, M. D., F. A. C. S., Rock Hill, S. C. (President's Annual Address.) My faith in heat in the treatment of cancer reminds me of a sermon I heard a noted evangelist make some few weeks ago as to how the different denomina- tions originated. His explanation was, that when Christ was healing the sick and restoring sight to the blind, in one instance, he had the individual to use spittle and clay as a healing agent, and in another instance he simply used faith, and from this, two branches of the church came into existence, the mudites and the non-mudites ; and so in a similar manner I have been considered a "Heatite," from my experience in the treatment of cancer. It has been proven by experimenta- tion that cancer cells are destroyed at a much lower degree of heat than are the normal cells of the body. Therefore, to my mind if heat is applied at a tempera- ture sufficient to destroy cancer cells and yet not sufficiently high in degree to injure the normal cells of the body the result is ideal. Heat is abundant, con- venient and cheap. This is of course, a consideration, other things being equal. The most convenient method of apply- ing heat is by means of the electric cautery, although in certain locations the soldering iron is suggested and used by Dr. Mayo, or the Paquelin Cautery is just as effective in case electricity is not available. In applying heat to the uterus for carcinoma, there is no bet- ter method of application than with the Percy Cautery devised by Dr. Percy of Galesburg, III, With this special cau- tery you are able to regulate the degree of heat, which is most important in the treatment of uterine carcinoma. While, as yet, nothing definite has been settled as to the cause of cancer, many theories have been advanced, but unfortunately each one has a question mark following it. We all know, however, that the ma- jority of cancers occur as a rule at some point of infection or irritation. The ^Prepared for the Tri-State Medical Asso- ciation of the Carolinas and Virginia, Nor- folk, Va., February 22-23, 1922. March, 1922. ORIGINAL COMMUNICATIONS 121 woman who has never borne children is not as liable to cancer of the cervix or breast as those who have. The stomach, gallbladder, rectum, lip, tongue and other points of irritation and infection is sufficient evidence to demand our attention. The man who smokes accepts a great- er risk of cancer of the tongue and lip than the man who does not, from con- stant irritation of the pipe, cigar or cigarette. And I fear when our next report comes in it will not be confined solely to men. The late Dr. W. R. Pryor at the New York Polyclinic many years ago advocat- ed the am.putation of the cervix in- stead of doing a trachelorrhaphy be- lieving it only left a favorable sight for a carcinoma to develop, therefore, pre- ventive measures should not be lost sight of. I know of no better method of ampu- tating a diseased cervix when it is hard and indurated than with the cautery ; it gives a most excellent result, and, at the same tim.e you have taken advantage of heat as a prophylactic measure. Dr. Balfour of Rochester uses the cautery as a preventive measure against cancer in the treatment of gastric ul- cers. Using the cautery in connection with gastro-enterostomy or other opera- tive procedures. In the treatment of any cancer with an ulcerating surface I can see nothing but failure facing any one who attempts any operative procedure regardless of the location unless the ulcerating sur- face has first been thoroughly cauteriz- ed to guard against any possible chance of ingrafting of cancer cells on- the de- nuded or raw surface. Aside from the late cases having sec- ondary involvment I consider the dan- ger of autogenous ingrafting of cancer cells on the field of operation the next most difficult problem we have to face in the treatment of cancer. I feel confident, however, that with the machinery which is ^aeing installed and put in motion by the profession in the way of educating the public of the early symptoms of cancer we will have fewer cases to deal with in the future which are directly due to delay. In all cases of cancer of the skin, they should be thoroughly removed with the cautery knife and as soon as the wound is in condition to be grafted this should be done. Usually this can be done un- der local anesthesia, removing the skin from some distant part of the body, it is as a rule not necessary to give a gen- eral anesthetic unless the area to be cov- ered is very extensive. The uterus I believe gets credit for furnishing 29 per cent of all carcinomas, and on account of the close proximity to the bladder, rectum and ureters it makes it most difficult to treat. Regard- less of whether you are dealing with an operable or inoperable case a Percy Cautery should always be done, and in the event it is an operable case and de- cide to remove the uterus, this should not be done until the slough caused by the cautery has separated and come away and we get a healthy surface. I remove the uterus from above as it en- ables me to make a wider dissection and after everything has been tied and cut down to the vagina as much of the va- gina is pulled up as possible and two kidney clamps are clamped, one on either side as far down below the cer- vix as possible and the vagina cut across with a cautery above the clamps, thus reducing to a minimum any chance of recurrence by autogenous grafts. On the other hand in case it is an inoperable condition the abdomen is opened, the cautery inserted into the uterus and slowly heated until your as- sistant, who holds the uterus in the gloved hand complains of it being un- comfortable, the tubes and ovaries are removed with ligation of the internal illiac arteries following the suggestions of Dearborne in the starvation treat- ment of cancer of the tongue. This treatment is based on the theory that cancer cells can not stand a temperature of 112 degrees for a longer period than ten minutes, whereas the normal cells have been grafted after having been subjected to a temperature of 130 tc 140 F. 122 SOUTHERN MEDICINE AND SURGERY March, 1922. of these qualifications. There are few CLINICAL OBSERVATIONS AND Medicine is the most difficult and in- RESEARCH WORK.* tricate of all the arts and sciences, and Pasteurs, few Newtons, few Ehrlichs. By John B. Deaver, M. D., and Stanley P. ^^ ^^^ confronted at every turn with Reimann, M. D. problems and confusion. If one indivi- "As clinical observers we study the dual, except he be of the very elect, can experiments which Nature makes upon hardly master the known facts and put our fellow-creatures. These experi- them to use, how then can any one ments, however, in striking contrast to mind both apply its acquired knowledge those of the laboratory, lack exactness, and at the same time explore new fields, possessing as they do a variability at Fortunately by combining the talents once a despair and a delight — the de- of two, or three, or more individuals, spair of those who look for nothing but we are able to muster the best, and es- fixed laws in an art which is still deep tablish principles with which to labor in the sloughs of empiricism ; the de- for the benefit of mankind, light of those who find it an expression -^he practical application of this com- of a universal law, transcendmg, even bination of talents, as no doubt you are scornmg, the petty accuracy of test-tube aware, has its beginning in the med- and balance, the law that m man, 'the j^al school. It is there that the most measure of all things', mutability, van- significant changes have been made and ability, mobility are the very marrow of parenthetically are still required, to lift his being." the study of medicine out of the slough In these words the immortal Osier, of empiricism, in which, to a great ex- himself the delight and the despair of tent, it still lingers. The medical school his admirers, characterizes the basic requires on its teaching staff" — and to my principles of the relation between clinical mind teaching is the essential function observation and research work, the sub- of a medical school — the services not ject I have chosen for my remarks this only of theorists but, more imnortant, of evening. practical, experienced clinicians, whose Osier makes it plain that medicine is observations among their patients nre- as yet not an exact science, but an art. pares their minds and those of their But it is fortunate for mankind that the Students for the problems living pa- boundaries of the art have been invaded tients suggest. For as Pasteur tersely and its frontiers gradually made nar- expressed it. "In the fields of observa- rower by science which not only routes tion, chance favors only the prepared empiricism and gives logical reasons mind." One of the significant changes for practices which have stood the test above referred to is the introduction of of time but adds new knowledge with laboratory methods into the regular which to carry on with greater certainty curriculum of the medical school. It is the battle for the control and perhaps in the "do-it-yourself" idea that the for the ultimate prevention of disease, student of today has Derhaps the great- To acquire an art, it is needless to say, est advantage over the student of for- takes time, takes unceasing enthusiasm mer time. By gradual steps he ad- and labor, takes experience. The acqui- vances from the simpler forms of lab- sition of a science demands a similar oratory work to the more complex prob- price. In both art and science, the first lems presented by the human labora- requirement is imagination, without it, tory. It is not, however, from the for- we cannot hope to produce either an im- mer sources that we should exnect to mortal artist nor an immortal scientist, derive the most valuable information. But imagination without observation, The observations made and the experi- experiment and comparison would lead ence gained m this school work should us no further than merely the door of be entirely preparatory, progress. It is rare that either the art- Without wishing to detract in any ist or the scientist is endowed with all way from the invaluable work that has emanated from the various research lab- Read by invitation by Dr. Deaver before the Oratories throughout the country, carry- 24th Annual Session of the Tri-State Medical mg on their work independently of a Association of the Carolinas and Virginia, hospital organization, I would like here Norfolk, Va., February 22, 1922. to record my conviction that the logical March, 1922. ORIGINAL COMMUNICATIONS 123 place for a laboratory of medical and ally well trained also in bacteriology and surgical research is in connection with physiology, and he is in a position to ap- a well-established, well-conducted mod- preciate investigations into functional ern hospital. "The experiments of na- activities of the body, normal and ab- ture" can best be observed, studied and normal. Most of the questions to be in- applied, in a laboratory connected with vestigated could be such as are of direct such an institution. I should therefore clinical value, although it must be rec- like to see more endowments assigned ognized that knowledge, provided it is to hospital research laboratories and in true knowledge, of even the most un- turn also I should like to see a more practical and seemingly academic inter- generous attitude on the part of hos- est, only awaits the magic touch of in- pitals in throwing open their doors to spiration, perhaps further work, to students eager to observe, perhaps later make it yield abundant fruit. Frank- to experiment, and finally to compare lin flew a kite in a thunder storm. To- the results of such observations and ex- day there is no need to cite the uses of periments. electricity. For our purposes animal ex- Every properly conducted hospital perimentation, I need scarcely say, is contains within itself the clinical ma- indispensable. And yet in our enlight- terial essential for stimulating imagina- tion, observation, etc. ; in other words ened country and in other supposedly enlightened countries legislators are every patient represents an actual or ^ent busy listening to the arguments of individuals who would perforce prevent the use of this beneficial and essential method of investigation. Our knowledge of most disease pro- cesses in their progress can be obtained in the mos^ convincing way only by ex- perimental work on animals. In our struggle for the prevention of disease we can use only animals who are suscep- tible to the disease under investigation. potential question-mark demanding at- tention. The real wealth of material necessary for practical research can be obtained only from the hosnital. With the study of each patient whether or not he has been cured, there must accrue a direct benefit to that patient or to his success- ors. Social betterment is the watch- word of our times, and it is a well rec- ognized fact that while the care of the i'!lK:Il"!^i^l"J":? ^Jll'^^'h f ""^ 1^1" sick is the primary and essential func- tion of the hospital, it is not the only one: quite as important is its dutv to endeavor to cure it. One of the main reasons for example, why v/e know so I'ttle of influenza, which in late vears that supreme question, the improve- J',^y^'''^^^ '"^^ ^^''°' ^""^"^ ^"'''''"- ment of the human race The matter of research carried on in conjunction with a hospital has been appreciated for a long time in European is because no one has yet suc- ceeded in transmitting the disease in its human form to an animal, so that it might be accurately studied. The value of laboratory work to the centers. Some of the most important surgeon is nowadays taken for granted and epoch-making discoveries in the In diagnosis it has its supreme function conquest of disease, as ^ye all know, in furnishing confirmatory and ofttimes have emanated from such institutes, positive evidence; no less valuable are Ihe work of Ehrlich, to cite probably the clinical tests which indicate the the most trenchant example, was not in state of functional activity particularly a medical trainine laboi'atory but in a of the kidneys and which are in favor or hosnital laboratory There is little against operative intervention in cer- doubt but that to this policv of estab- tain cases. To the experimental physi- lismng hosmtal laboratories not only of ologist. the surgeon owes his knowledge pathology, but of bacteriology, physiol- of how far he can venture in radical ogy, chemistry and all allied sciences, surgery; knowledge which he would Cxermany, for example, owes much of never have dared to obtain from the the conspicuous place which she achiev- human subject as the experimental ob- ed during the last half century. ject. On the other hand, when a bril- The head of the laboratory should be liant flash of the imagination, which so preferably a pathologist, because path- often comes in the presence of an emer- ological anatomy is still the most im- gency, has suggested a new operative portant of the fundamental subjects, procedure, the laboratory investigator Furthermore a good pathologist is usu- immediately begins to study the safety 124 SOUTHERN MEDICINE AND SURGERY March, 1922. of the method and its rationale. A striking exampl^e of such a circumstance is the operation of gastrojejunostomy which has become an very-aay procedure in most surgical clinics When confronted with an inopera- ble carcinoma of the pylorus, Wolf- ler was about to close the abdomen his assistant Nicoladini, suggested anas- tomosing the small bowel with the an- terior wall of the stomach, thus provid- ing a new exit for the food. Although the operation in its original form prov- ed a poor one from a physiological standpoint, it formed the basis of study for development of the methods now in use which have proven of such marked benefit to a large class of sufferers from abdominal disorders. It is difficult to find a more significant example of the value of clinical observation to surgical research, than this simple operation. Asrain, the clinician is often able to ap- ply nature's experiments in a practical way to his surgical work. I need only to mention such a phenomenon as a snontaneous cholecysto-enterostomy, which is often as successful in relieving distress as the artificial anatomosis which the surgeon imitating nature oc- casionally uses. These and numerous other instances which I might cite, show the importance of well equipped laboratories as an inte- gral part of a modern hospital. I must emphasize the human as well as the material equipment. For without a well trained staff of workers in the lab- oratory, we can make very little prog- ress in our problems. It should be the f imction of such a research staff to keep abreast of all new suggestions, to offer new methods and to extend knowledge by verification and exoeriment, and on the other hand, the wide-awake clinician with problems staring him in the face, should make the best use not only of the hands of this laboratory staff, but of their brains as well. Sir Almoth Wright has said that "laboratories not attached to hospitals cannot turn out good work without stimulus of fresh material from the hospital, they suflFer from paucity of ideals." They, I believe, also lack' the mutual insipration to be derived from the working together of the clinical and the laboratory staflF. The present era is without doubt the era of combined research based on the correlation of clinical observation and experimental inquiry. To it surgery owes its wonderful forward strides since the day of Pasteur and Lister. It is only by the further development of this team work between the hospital and the laboratory that the former can prop- erly perform its function in caring for the sick and the suffering, and the lat- ter can hope to make worthy contribu- tions to the ideal that animates the sci- ence and the art of medicine, the pre- vention and eradication of disease. RAMBLING REMARKS IN RE APPENDICITIS* By Stuart McGuire, M. D., Richmond, Va. Appendicitis was first clearly recog- nized and accurately described by Regi- nald Fitts, an internist of Boston, in 1886. Before that date the symptoms due to the disease were attributed to gastritis, peritonitis or inflammation of the bowels. Robert T. Morris said that if a torch was applied to the tomb of every man dying of unrecognized appendicitis the world would be a bon fire. I have often wondered how a con- dition which was so frequent and fatal could have escaped recognition by clin- icians of the past who were justly noted for the accuracy of their observation. The explanation lies in the fact that the symptoms of appendicitis, originating in an organ without function, were characterized by reflex disturbance of the function of other and more impor- tant organs and hence were miscon- strued during the life of the patient. If death ensued and a post mortem was made the secondary complication so ob- scured the original lesion that it was overlooked. Dr- H. H. Henkle of Staun- ton told me that while in New York tak- ing a post graduate course in 1878 he saw a case in the wards of one of the hospitals which was treated first for gastritis, then for peritonitis and finally for locked bowels. When the patient died a post mortem was- held and the pathologist commented on the fact that the inflammation had been so severe that the appendix vermiformis had sloughed off. Two years later when engaged in private practice this physi- * Paper read at the meeting of the Tri-State Medical Association of the Carolinas and Vir- ginia, held at Norfolk, Va., Feb. 22-23, 1922. . March, 1922. ORIGINAL COMMUNICATIONS 125 cian saw another case die with similar E. Fields of Norfolk. The prize essay symptoms and before making a post was published in the Transactions of mortem he told his colleagues that he the Society for 1894 and may be read was certain that they would find the with profit today- McBurney was the appendix ga^ngrenous and such proved first to advocate the interval operation to be the ease. In neither instance did for appendicitis and to suggest the split it occur to any of the physicians that muscle incision now known by his name, the condition of the appendix was the He said the method required four as- pririary cause of the trouble. sistants and that the work could not be From a surgical standpoint appendi- done in less time than one hour, citis and I are about the same age. Like ^ All this of course is ancient history, the rabbit that was born and bred in a but it is history that some of us have briar patch, so I received my earliest forgotten and others have not learned professional experience in the midst of Appendicitis is as frequent today as it a discussion and contention with refer- ever was, and it is still the cause of ence to the cause, diagnosis and treat- many deaths that might be prevented, ment of appendicitis that created as Most of the problems with reference to much interest and feeling as did prohi- its diagnosis and treatment have been ytion, woman suffrage or the recent solved, but the disease has lost its charm controversy with reference to the pro- ^f novelty, and I fear the dearly earned posed consolidation and location of the experience of the past is not being two State aided medical schools in Vir- properly transmitted to medical stu- •j^j^ dents or the new generation of practi- ax" 1.1. x- i? u- L. T 1 4.V, tioners of medicine. At the time of which I speak the j^^^^^^^ j^ reading the statistics of pages of medical lournals and the pro- ^^^ operations done at a famous hos- grams of medical societies were almost j^^j J^ ^^^.^ country, I was struck with monopolized by papers on appendicitis, ^^^ ^^^^ ^^^^ one-third of all the pa- xvhich discussed the influence of age ^.^^^^ ^^^^^^ operated on for appendici- sex and race the etiological factor of ^j^ j ^^^^^^^ ^^^^ j ^^^^ astonished at grape seed and other foreign bodies, the ^^^ ^ ^^^ ^^ investigation of my question of whether chronic dyspepsia ^^^,^ ^^^^^^^ ^^^ ^^ j^ i ^^^^ng cer- was a cause or a result of the disease, ^^j^^ ^^ ^^-^^^^ ^^^^^^ ^^at practi- the possibility of making a definite diag- ^^jj^, ^^^ ^3roportion was true in Rich- nosis before the development of a mass ^^j:,^ Surely a disease so frequent m the lo^yer right abdomen, whether ^j^^^j^ continue to occupy a large part appendicitis should be regarded primar- ^^ ^^^ ^^^^^^ ^^^ ^^^^ ,ly as a medical or surgical condition, ^^^^ ^^ ^^^^ ^^ consider the pres- whether purgatives were beneficial or ^^^ mortality of the disease the results m.lurious in the early stages, and finally ^^^ equally 'impressive. Certain indi- the indications for operation and the vidual surgeons working under favor- time at which It should be done. On ^^j^ conditions are able to report long these and many other pomts there was ^^^,.^^ ^^ operations, which include not rreat difl^erence of opinion. Murphy ^^j^, ^^^^^.^ ^^^ ^^^^^ ^^^^^ ^^ ^,1,,- Price. Ochsner and others held joint ^,.^^ ^ ^^^^^ ^^^^ ^^ 1^^^ ^^^^ o-'c But discussions at^the meetings of all Na- this bv no means represents the work of tional associations that for brilliancy ^^^ ^.^^^ ^^^ ^1^ ^^ ^^^ profession. The and bitterness have rarely been equaled j^^^ lamented John B. Murphy recog- even in political debate. In Virginia my ^-^^^ ^^is fact, and realized that to ar- father. Hunter McGuire was regarded ^.^^^ ^^ ^^^ ^^^^^ ^„ investigator should f" Is^n'o^'i^ "" kTITT *^^ subject and ^^^ ^^^^^ ^^^ ^^^^^^^ ^^ ^ fe,,, surgeons, in 1892 he published a paper entitled ^^^ ^^^ '^^ ^^^^ ^^ hospitals. He Seventeen Consecutive Unselected therefore in 1915 compiled the statis- Cases of Appendicitis Operated on With ^j^^ ^^ ^^^ hospitals in the United States One Death So great was the local in- ^j^^^ published annual reports, and terest m the subject that the Medical fo^nd that they showed the average Society of Virginia, in order to stimulate mortality rate of appendicitis both acute study and investigation, offered a cash ^^^ chronic was over 10-; . When it is prize for the best paper presented by remembered that the large majority of one of its members, and this was won these cases were interval operations and after a vigorous competition by Dr. E. that as a, rvile th§ hospitals that publish 126 SOUTHERN MEDICINE AND SURGERY March, 1922. reports are superior to those which do not do so, it is obvious that the mortal- ity of acute appendicitis in the United States today is still very high. The object of this brief paper is not to discuss the treatment of appendicitis, because it has become standardized with perhaps the single exception of the question whether to operate in the face of an existing and spreading infection or to wait with the hope, sometimes realized but sometimes futile, that there will be a localization of the septic pro- cess which will render surgical inter- vention safer- My object is to empha- size the frequency and fatality of the disease and to urge that it be discussed at our medical meetings and thoroughly taught in our medical schools, because despite all the time and study which has been devoted to it in the past, it con- tinues to cause a large number of pre- ventable deaths. We do not need new facts and theories, but we do need to see that the accepted principles of treat- ment are universally known and put into practice. Further publicity is nec- essary to educate the laiety against the administration of purgatives, the fam- ily physician on the importance of early diagnosis, and the surgeon on the wis- dom of prompt operation. So much has been written about the unnecessary operations that have been done for appendicitis in the past, and so many new diagnostic methods have been introduced to prevent error, that there is a tendency on the part of some surgeons to postpone an operation in a doubtful case until a diagnosis by ex- clusion can be made. Unnecessary op- erations are, of course, to be avoided and accuracy of diagnosis to be encour- aged. It is admittedly very mortifying to the surgeon if he operates on a case for appendicitis and later finds the pa- tient was suffering from pneumonia, acidosis, pyelitis, or stone in the kidney, but it is disastrous to the patient if he really has appenditis and the disease is allowed to progress to a hopeless stage while the surgeon is eliminating the possibility of error by X-ray examina- tions, catheterization of the ureters, and time consuming laboratory tests. All cases should, of course, have a nhysical examination of the heart and lun.e-s. a differential blood count and a r-rcfnl urinalysis. In some cases where there is absence of tenderness or rigid- ity in the lower right abdomen, a rectal examination or palpation of the loin will show a displaced appendix. These ex- aminations can be completed while the operating room is being prepared and need cause no delay. If the findings point to appendicitis and the patient's condition is acute I would operate even if the diagnosis was not conclusive. In following this plan I must confess to having made some mistakes, but I know I have saved many lives which would otherwise have been sacrificed. An op- eration in itself carries little risk. If the appendix is innocent the patient will recover, and if necessary can be operated on a second time. Better a living mistake than a dead one, although dead men tell no tales and play no part in the reports and statistics of other surgeons. I wish to make it plain that what I have said applies only to acute appen- dicitis. Just as I am radical with acute cases, so I am conservative with chronic ones- In acute cases no time should be lost in an attempt to establish a definite diagnosis. In chronic cases no time should be spared to eliminate every pos- sibility of error. The patient's life is not in danger, and his restoration to health depends on the location and cor- rection of the cause of his symptoms. In these cases not only should every possi- ble diagnostic means be exhausted be- fore the operation, but as a rule the abdomen should be opened by an inci- sion which will permit of a thorough and complete examination of all its va- rious organs, in order to determine whether the appendix is the real and sole malefactor. AUTO-TRANSFUSION* Charles S. White, M. D., F. A. C. S., Washington, D. C. The surgical profession at large cred- its Crile with placing blood transfusion on a workable basis, and it remained for the World War to give it the impe- tus it so well deserved. Regardless of the many methods in vogue at the pres- ent day, and without discussing the rel- * Read before the Tri-State Medical Asso- ciation of the Carollnas and Virginia, Nor- folk, Va., February 22-23, 1922. March, 1922. ORIGINAL COMMUNICATIONS 127 ative merits of each, the fact remains lution, or a solution of sodium citrate, that transfusion is a procedure in sur- Later a ladle or spoon was used for the gerv which has a very definite place, same purpose. We have found that the and is no mere passing fancy. Balfour aspirator was ideal, permitting Most of us are familiar with direct thorough and quick method of obtaining and indirect methods, and possibly also it and we do not agree with the state- with the so-called auto-transfusion, by ment that the aspirator traumatizes the which is meant the patient's own blood, blood more than the slower ladle lost by internal hemorrhage, is intro- method. The motor or hydraulic as- duced"into his circulation. It is some- pirator certainly accomplishes the same times called re-infusion. It is this phase result in less time, with less injury to of transfusion which we wish to discuss, the viscera and more completely than To Thies, a German gynecologist, is can be done in any other way given the credit of first employing auto- We have proceeded in the following transfusion clinically, and in his report manner: As soon as the abdomen is in 1914, he cites three cases of extra- opened, having previously sterilized all uterine pregnancy in which he baled Parts of the aspirating outfit which blood out of the abdominal cavitv, mix- come in contact with the blood, and 50 ed it with salt solution and injected it c.c. of 21/2^. of sterile citrate of soda into the veins of his patients. All re- solution having been placed m the re- covered. Other German operators have ceptacle, the nozzle of the aspirator is taken ud this method, and reports have introduced into the peritoneal cavity been published bv Eberle, Henchen, and the blood removed. If morfe than a Lichtenstein and Schweitzer, the latter P^nt is obtained, a second 50 c.c. of in June, 1921, citing twentv-one cases sodium citrate is added to the container- in which he re-infused the patient's own ^n excess of citrate does not appear to IglQOfj be harmful. The source of the hemor- The blood for such purposes is usu- ^^^^^ is. found and receives appropri- allv found in the abdominal cavitv as ^^f surgical treatment. If a ruptured fv^o i^ocnif r^f r„r.+„^^ r.f fi^^ i,-,.«^ ar^L^r. mtestinc IS fouud or any gross contami- tne result or rupture or the nver, spleen, ^_^,. . ,, ui^^^ ,•„ ^^v, +1.^ u^^^A or uterus, iniurv to the mesentery, or "^^^«" 9^ the blood is seen the blood extra-uterine" hemorrhage. One opera- .^^""^ ^' Tf^' ^^ "*^^'^. ^ ^^ tor has used blood from the pleural ^^^" poured through gauze mtx) the m- cavitv. but this source, as well as that ^fT outfit and introduced into a vem f».^rv," ^\,^ „f..,<„o c.««rv,o u ^a: ■ +•« of the arm bv an aasistant without in- hlP RWH f >.; ''^"^l^^l^ly -l^^tifia- terrupting the operation. We have used ^n.f hi inlp «' " ? this purpose, from 500 to 750 c.c. of blood, believing must be above suspicion in so far as in- ,, ,1 j.-^. • \ -j.^ + fection is concerned. It has been stated ^^at a larger quantity is not without by comnetent observers that during ^^"^^\f .^"^^^^^^^^"f ^^^^T^- ^e health, the liver blood frequentlv holds Jfve obtained more than 1000 c.c of pathogenic organisms in su^spension. ^^^L'-^Zl'^^r^t^^^^^^^ Blood which has disinteerated loses ^^er 750 c.c. It mav be possible, al- many of its desirable qualities, and it though we have never done so, to re- has been noted that the older the blood, frigerate the blood from the abdomen that IS the longer period after hemor- ^nd keep it in reserve for the particular rhage, the less its value as a transfusion patient from whom it was removed, or agent. In the peritoneal cavity, blood foj. ^nv other suitable case. It has al- retains its morphological character ^.^vs appeared a needless waste to see much longer than the same blood ex- 506 to 1000 c.c. of blood removed from nosed to air. The clotting of blood in- the abdomen and emptied into a bucket terteres ohysically as well as chemically of soiled sponges in its adaptation for this purpose. The t> ' 4.- j^ u ■ 4. .e • ^lr^+c, ■i,^„r^,.^», u ^ M^^c. ± c Re-actions following transfusions, ir- clots. however, can be strained and -• ^ xt. tZ j l j- ,' J_^ \ ,, ^-^tidiiicu ciiiu respective of the methods, are not dis- washed, so that they are not a total similar, the chief characteristics being a ^oss. chill, rise of temperature and aching In removing blood from the perito- of the back and limbs- The percentage neal cavity, in the early report of cases, of reactions in transfusions vary great- sponges were dipped into it and wrung ly according to the various reporters, out over a receptacle containing salt so- apparently depending upon the tech- 128 SOUTHERN MEDICINE AND SURGERY March, 1922. nique, typing- and condition of the re- cipient. One re-action in every two to five cases has been recently reported by Bernheim. We had two re-actions in six cases of auto-transfusion. Wheth- er these reactions were due to the blood re-infused, which had undergone some change, chemical rather than physical, or whether the additional stress of the operation that the patient must bear, are conditions which have not been ap- parent, and as far as we know, have not been investigated. A patient who has a traumatized abodmen with acute ex- cessive hemorrhage cannot be compar- ed, from the standpoint of reaction, with the case in which transfusion is commonly done. We can simply state that in our brief experience the reac- tion in auto-transfusion is more fre- quent than in other methods. Auto-transfusion is indicated in ac- tive hemorrhage in the abdomen, of such gravity as to jeopardize the life of the patient if no other means are at hand to supply the blood. Contamina- tion of the blood in any manner, either by the nature of the injury or in prep- aration of the blood, contra-indicates its use. Extra-uterine preg-nancy would seem to be the ideal indication for auto- transfusion and has been the most fre- quent condition in which it has been used. Better diagnoses have reduced measuredly the mortality in ectopic g^es- tation and the necessity for transfusion is infrequent, but when the necessity does arise, the larger hospitals and com- munities are usually able to supply a donor on brief notice. The best laid plans go astray at times and likewise the diagTiosis. It is when the ruptured tube with the hemorrhage is unexpected or the picture moves with unusual swift- Tiess that auto-transfusion is an agency that meets the requirements. In rup- ture of the liver, spleen, gunshot wound of the mesentery, the volume of hem- orrhage, the call for speed, and the delay in obtaining a donor, justifies the use of auto-transfusion. We feel that blood from a ruptured uterus, or from the pleural cavity should not be used for this purpose although some operators have done so. The advantages that seem apparent are (a) large quantity of blood immedi- stelv available when there is urgent reed '-f it; (b) typing and Wassermann is not necessary. These are offset by the possibility of contamination- When time permits, and a tested donor is available, auto-transfusion should not be considered the method of choice. We wish to report one case briefly : J. B., colored, 18 years of age, was admitted to the Emergency Hospital November 21, 1921, for contusion of the abdomen following a fall over a con- crete frame. He was treated by the interne for contusions and shock and kept under observation in the rest room several hours, but as his condition did not improve he was admitted to the ward. Here apparently his condition did not excite the interest or attention that it deserved and not until about twelve hours later was it realized that he was very ill. We saw him about twenty hours after the accident. It was plain that he was suffering from a grave intra-abdominal injury and the diagnosis was hemorrhage or rupture in the gastro-intestinal tract. Dullness in the flanks pointed to hemorrhage. A medium sized needle on a 10 c.c. syringe was used to aspirate the abdomen, di- recting the patient to turn to the left side to promote the gravitation of fluid to that side. Plunging the needle through the abdominal muscles, it could be felt to pass into a nonresting area and, upon withdrawing the piston, the syringe was filled with blood, which subsequent- ly proved to be sterile. A portion of this was examined on a slide, and show- ed no change in morphology, of the cells. The routine blood examination at the time showed R. B. C. 2,800,000, W. B. C. 17,000, Hg. (Dare) 45. The only donor obtainable of the proper type was secured several hours later. The pa- tient was transfused and the abdomen opened. The peritoneal cavity was lit- erally filled with liquid blood. This was aspirated into a jar containing ci- trate solution. No wound was found in the stomach or intestines, but a long, deep laceration was distinctly felt in the diaphragmatic surface of the right lobe of the liver. This was packed with gauze. The patient was auto-trans- fused injecting 500 c. c. into the vein of the right arm. The convalescence was long and stormy. Considerable sterile blood was later removed from the right pleural cavity and an abscess between the liver and the diaphragm, showing the Fried- lander bacillus, was drained posteriorly March, 1922. ORIGINAL COMMUNICATIONS 12J about four weeks from the outset of his irritate the dural endings of the 5th illness. Not having time in which to do and 10th nerves; and in like manner a Wasserman on the donor before trans- the headache of excessive bodily and fusion, blood taken at the time subse- mental exertion and emotional disturb- quently proved to be four plus- We were ances may be due to the irritant effect confronted with the possibility of hav- of accumulated fatigue toxins on the ing introduced syphilis by transfusion, brain and dura. Repeated tests of the patient's blood for Headache is an extremely common four months were Wasserman negative, symptom. There is probably no organ however. His recovery was complete at in the body damage to which is not ac- the end of four months. companied at some time by symptom- This case was the first in which wt atic headache- It may be one of the used auto-transfusion and satisfied us first symptoms of severe disease, and with the facility and safety of its appli- for this reason every patient present- cation. We have used it five times since, ing himself to the physician with the Another feature which appealed to us complaint of headache must be submit- was aspiration of the abdominal cavity ted to a minute and complete examina- for diagnostic purposes. Puncture of tion. the intestine by such proceedure is at- Migraine is perhaps the commonest of tended with more theoretical than real all forms of chronic headache. When danger. We have only to recall with typical attacks occur their recognition what contempt for danger the Roent- is easy, but the less complete the at- genologist employs the needle for pneu- tack the more difficult becomes the dis- mo-peritoneum X-ray photography to tinction between true migraine and verify this. We have aspirated the ab- symptomatic. Points of value in the domen repeatedly with most gratifying dift'erential diagnosis are: results. (1) Heredity— in 90% of all cases of The introduction of the blood of a migraine, syphilitic into the circulation of a pa- (2) Periodicity of headache and its tient free of the disease does not neces- occurrence in attacks, sarily transmit the disease, but this is /o^ r^ i. ■ ^ ^^^^ /•£ 4. •« not a new observation; it but confirms ^ ^^^^^'V? T'^^a ^ ' ^'t °!!f^^, other clinical reports. beyond the 3rd decade we should sus- We do not hold a brief for auto-trans- Pect some other cause.) fusion, but merely present it as a After migraine the neuraesthenic (or method having a limited field of appli- exhaustion) headache is the most com- cation and mav succeed in saving the "^o" type. It differs from the headache hundredth case. that any normal individual may have after mental or physical exhaustion only in the degree of its severity and its HFADArHF WITH F^PFriAT RFF chronicity. In the neuraesthenic type Jl\JZu^i -i-^ ^L.ITo IVrT there is usually no actual pain except EKENCL TO THOSE DUE TO temporarily after violent emotional dis- SINUS INFECTION* turbances, but a pressure, constriction H. c. Shirley. M. D.. Charlotte, N. c. ^i^^. heaviness in the head They com- plain of a sensation as if the skull were Headache in the strict sense of the squeezed in a vice"; "a tight rubber term is a pain felt in the interior of the band was about the head"; "a sense of skull, and is due to irritation of the pressure in the forehead on both sides, dural branches of the trigeminal, or extending down into the eyes and root vagus nerves. of the nose" ; or pains of neuralgic In cases of cerebral tumors the head- character which shoot through the head, ache is due to the increased intra- first in one place and then in anothe cranial pressure which produces a di- but without limitation to any definite rect irritation of the nerves in the dura, nerve area. Many of these patients In febrile disorders, particularly influ- state that they "cannot remember when enza, the circulating toxines probably their heads were free from discomfort." The sense of heaviness is often most • Read before the Tri-state Medical Associ- marked in the morning. There is usu- ation of the Caroiioas and Virginia, Norfolk, allv no nausea nor vomiting associated Va., February 22-23, 1922. With the neuraesthenic type of head- 130 SOUTHERN MEDICINE AND SURGERY March, 1922. ache, and no history of heredity. Long cavity below the middle turbinate, continued bodily or mental exhaustion, 2. The posterior group mcludes the chronic focal infections, eye strain and sphenoid and all ethmoidal cells that insomnia are important etiologic fac- open into the nasal cavity above the tors middle turbinate. The common causes The rheumatic or nodular headache of all infections of the nasal sinuses that is so common among the Germans ^^^- ^ ^, • -? .• • • and Scandinavians is frequently mis- 1. Coryza-the infecting organism is taken for a headache of sinus origin. It most commonly the streptococcus hae- occurs almost exclusively in women of molyticus (occasionally the viridans), middle and advanced age- It is describ- pneumococcus (type 3 and 4) the staph- ed as a persistent severe pain that in- Jococcus and the influenza bacillus. If volves the whole head, but almost with- there is any chronic nasal obstruction out exception begins in the occiput and «" one side the sinuses on that side are back of neck and frequently radiates more liable to become infected than are downward toward the shoulders. Fre- those on the other side, quently repeated chills of various kinds, 2. Abscess at the root of one of the such as draughts associated with occu- upper molar, or bicuspid teeth, pation; using cold water on the head af- ^J- The regurgitation of vomitus into ter shampoo, and changes in tempera- the nasal cavities during an anaesthetic ture such as effect patients with arthri- Perhaps not more than one half of tis, are important etiological factors. the patients with chronic sinus mfec- The general physical examination in tions ever complain of headache. All these patients is usually normal but on ^^^^^ .^\th an acute sinus infection have palpation of the scalp tender subcutane- P^^' ^/ there is sufficient oedema of the ous nodules can be felt in the subcutane- "^fv.t^ obstruct drainage When the ous tissue and in the muscles over the infection is due to a streptococcus the occipital region. patient is much more liable to have pain _^f . .. „ ... .., ., . than if the infection is due to some The majority of patients with this o^her organism type of headache have extensive sinus j^ ^cute infections of the frontal and operations before they get into the antrum there is local tenderness on hands of some one that recognizes the pressure over the affected sinus. The true nature of the headache. p^jn ig referred to the forehead, the The headache of cerebral arterioscle- inner angle of the orbit and floor of the rosis is extremely severe, is usually lo- frontal sinus, over the antrum and in calized on the top of the head or in the the upper teeth on the affected side, occipital region. It is characteristic of ij, acute infections of the sphenoids this type of headache that It is greatly ^nd post ethmoidal sinuses the pain is relieved (temporarily) by the adminis- usually referred to the bridge of the tration of caffeine Many of these pa- ^ose, to the forehead at the level of the tients are in the habit of drinking coffee gye brow and in the eye ball. In our as soon as they get out of bed in the experience infections of the sphenoids morning for relief of the headache. ^nd posterior ethmoids cause head- The pain that occurs in association ache that is localized in the front part with infections of the accessory nasal of the head on the affected side, sinuses is usually referred to some area In chronic infections of the sinuses within the anatomical distribution of there may be a headache that is due to the 5th nerve. Rarely do these patients a combination of several factors : complain of pain in the occipital re- i. Obstruction to drainage of the in- ^lons. fected sinus. The m.m. of the nasal cavities; of 2. Absorption from the sinus, which all the accessory nasal sinuses, and that is a chronic focal infection- of the mastoid cells is innervated by the 3. To the long continued swallowing 5th nerve. For clinical purposes the ac- of mucopurulent discharge, cessory nasal sinuses are divided into 4. To neurasthenic symptoms that two groups : ni^y be primarily due to the above con- 1. The anterior group includes the ditions. frontal, antrum of Highmore and all 5. An exaccerbation of a migrainous ethmoidal cells that open into the nasal type of headache. March, 1922. ORIGINAL COMMUNICATIONS lH In many cases of chronic frontal sinus ocular origin may be due to a latent infection, however, the pain is sharply sinus infection. localized over the area overlying the (7) in general all headaches associ- affected sinus. ated with infection in the accessory na- In chronic infections of the sphenoid sal sinuses are referred to the area of and posterior ethmoidal cells the head- distribution of the fifth nerve. These ache is most commonly referred to the patients rarely complain of a headache frontal regions, the bridge of the nose in the posterior half of the head ; when and deep in the orbit. Pain in the ear they do, it is due to a combination of the and in the mastoid is also frequently sinus headache with that of some other complained of, when the infection is lo- type, calized in these sinuses. Cancer. Surgeon in Chief, Wesley Long Hospital, Greensboro, N. C. Summary The chief points we wish to empha- CANCER PROPAGANDA* size are : (1) Headaches due primarily to By John Wesley Long, M.D.. F.A.C.S. sinus infections are worse in the morn- Emeritus Professor Diseases of Women, Medi- ing. We rarely get a history in these cal College of Virginia. cases of headache that begins in the aft- Director American Society for Control of ernoon. (2) In both the acute and chronic in- fections of the frontal sinus the head- ache is usually in the forehead or the affected side, and there is tenderness on I accepted the call from your Secre- pressure or on percussion over the tary. Dr. Hall, to address this distin- sinus. guished Association of physicians and (3) In the acute infections of the an- surgeons because it is through you that trum the pain is over the antrum, there we hope to reach the public with the is tenderness over the antrum, and often truth about cancer. I hasten to say that neuralgic pain in all the upper teeth on I bring you no new doctrine, but I do the affected side. This latter symptom come with a message of hope for your is due to the anatomical distribution of patients. the second division of the fifth nerve. Outstanding Facts About Cancer (4) In chronic antrum infections Certain facts regarding the subject there is usually no local pain or tender- stand out with startling clearness. Let ness. These patients complain of head- him read who runs: ache in the frontal and parietal region 1. Cancer is prevalent throughout the on the same side- world. (5) In both acute and chronic an- 2. Cancer is strictly an individual dis- trum infections there may be pain re- ^^^^ ^^^"^ neither contagious nor here- ferred to the mastoid. This is not an ^itary^. uncommon symptom of an impacted ^- Cancer is the most fatal disease we wisdom tooth, and is explained by the ^"o^^'- Ninety-nine per cent of the cases fact that the m.m. of the mastoid cells P^ovrng fatal if allowed to run its is supplied by the trigeminus. ^'^y^^", , , , (R\ Tr, K.^fu fv,^ „ „+ J u • • 4. The annual death rate from can- fpAfnn. of th. Lf ^"d Chronic in- ^^^ -^ ^^^ United States is 78.9 to the snhpnotd. thp .f.in '''" f^'^f'l' ^,^^ 100,000 population; or more than 85,000 ?orehP.J«nS hS " f f^^""''"^ l^ ^^^ deaths each year. This means that one npr «ntl f f if ^ K > ^ % '!?'^' ^^\T P^r^on dies every six minutes from can- ner angle of the orbit and deep in the ^er ^nr:. i^'ll^T)^ ""? tenderness on pres- 5. while the death rate from typhoid thPnn!!. fronta sinus or bridge of fever, tuberculosis, malaria, pneumonia or P?hmn?l?^^ f ^ /'!*^^ '" an anteri- and even old age is constantly on the or ethmoidal or frontal sinus infection, decline, that from cancer is increasing Pain in the ear and behind the ear is not infrequently associated with infection *Read before the Tri-State Medical Associa- in the posterior ethmoids and sphenoids, tion of the Carolinas and Virginia, February Many ot the headaches of supposedly 22-23, 1022. 132 SOUTHERN MEDICINE AND SURGERY March. 1922. at the rate of about 2 per cent annual- ly. For instance, the death rate in Massachusetts in 1871 was 39.9 per 100,000 while by 1911 it had increased to 92.6. The death rate in the United States in 1900 was 62.9 and in 1918 was 78.9. In European countries the death rate in 1881 was 44.8; in 1911 it was 90.4. 6. Cancer is a disease of adult life. Eighty-five per cent of those who die from it are 45 years old or older. Of those reaching 40 years, one man in every 12 and one woman in every six die of cancer. 7. Fifty thousand lives might be saved every year by an intelligent co- operation between the profession and the laity. The Duty of the Profession In the light of these facts are we do- ing our duty in the matter of educating the masses of the people concerning the great scourge of cancer? We, who sometimes arrogate to ourselves the title of "guardians of the public health ?" As I write this address, there are ly- ing in the hospital rooms adjoining three patients whose abdomens I have opened. One has an inoperable cancer of the gall bladder and liver, which started evidently from chronic irrita- tion due to gall stones. One has a can- cer of the head of the pancreas, caus- ing obstruction of the duodenum and for whom I could only do a gastro-en- terostomy. The third has a widespread cancer of the stomach which has no hope except the makeshift of side-track- ing the mass by gastro-intestinal anas- tomosis. Two other patients have can- cer of the breast with metastasis for whom we are using radium, because for- sooth there is nothing else we can do. We all have these cases — like the poor — they are with us always. The point is they are all late cases. The moral is "Why are they late?" Scientific Papers Efficient But Not Sufficient I submit that while it is efficient for us to read scientific papers before learn- ed medical bodies, yet it is not suffi- cient if we wish to reach those who suffer. We must get down upon the level of the average man and speak to him in his own language. Recently, I had the honor of addressing a mixed audience fi^om the same platform with the incomparable Howard A. Kelly, upon the subject of cancer. No man speaks with greater authority than does Dr. Kelly. He delivered one of the finest addresses I ever listened to; it was a masterpiece. He told them all about radium, uranium, eminations and other scientific entities. He went so deeply into his subject that he apolo- gized to the laity present because he had to use highly technical terms. I followed Dr. Kelly and apologized to the doctors present because I avoided technicalities and spoke the language of the people. Most of what the profes- sion knows about cancer is entirely too scientific and mysterious for the average citizen, much less the ignorant and unlearned, to understand. The Eunuch and Phillip You remember the story of the eunuch who had charge of the treas- ures of Candace, Queen of Ethoplia. As he was riding in his chariot he read the book of Isaiah. Phillip meeting him asked if he understood what he was reading. The eunuch replied "How can I except some man guide me?" Sup pose we do like Phillip did, get up in the chariot and sit down by the people and teach them. If we are to maintain our responsible position as sponsors for the health of the community we must turn the light of truth into the darkness of ignorance, that the crooked places may be made straight. If we continue our present attitude of aloofness and exclusiveness, we cannot censure the people for be- lieving the tommyrot taught by can- cer-quacks, chiropractors. Christian Sci- entists, et al. Public Opinion a Matter of Education. You know that public opinion upon any subject is largely a matter of edu- cation and growth. Why, it has not been many generations since we burnt witches, even now we burn sexual man- iacs at the stake. Well do I remember human slavery and the defense our Christian parents made in defense of it. And we .all are familiar with our recent toleration and license of the liquor traf- fic. March, 1922. ORIGINAL COMMUNICATIONS 133 American Society for Control of Cancer stress this great truth too much No IS Educating the Laity matter in what part of the body cancer Therefore, we do not hesitate to say starts it is there and nowhere else. The that the American Society for the Con- ^^^^ that cancer is in the blood from trol of Cancer, which Society I have the ^^^ ^'^H' first is erroneous. Let us tell honor to represent, is trying to educate ^^^ people that it is as false as the the common people concerning cancer, righteousness of burning witches. Let's the most fatal of all diseases. I hasten Set this fact firmly fixed in their minds, to add that it is through the ethical Regardless of what they have heard channels of the profession that we '^[^ people say, cancer is always a local would spread the propaganda. disease when it first appears. The Cause of Cancer Cancer is a Blood Disease Only XT , . • • , , Secondarily Now what IS It we should teach the people? P'irst, let us eliminate what The second fact of importance is that they do not need to know. later cancer does get into the blood, and It is not necessary that the public becomes disseminated throughout the should know the exact cause of cancer, whole body. When this takes place it No one knows, for that matter. The ^^ liable to ''break out" anywhere. This cause of many of the most common dis- breaking out of cancer in parts of the eases has not yet been discovered. Take body distant from the original site is measles as an illustration. Yet any called "metastasis." These are the cases country housewife can take her hot that are absolutely incurable. herb teas and cure any ordinary case of j c *• mi i^i mi , .. measles Infection Takes Place Through the We are curing more and more can- Lymphatics cers every day, even though we do not The invasion of the general system know its primary cause. takes place usually through the lym- We may say in all candor that cancer phatics. Even the laity know that a is. not a germ disease. In saying this I sore anywhere on the hand causes a am not unmindful of the fact that in "kernel" to form under the arm. The Sir Berkly Monyhan's Hospital at Leeds, lymphatics are tiny vessels, smaller p]ngland, there is being carried out at than the finest sewing thread, that ram- this time certain experiments trying ify in every part of the body. Their out the theory that cockroaches have function is to suck-up or absorb any in their cecum a worm which is sup- unusual deposit anywhere in the body, posed to carry a parasite which in turn They carry the absorbed material to the causes cancer in the stomach of rats. general circulation, where, if it be pois- Fortunately, there are large endowed onous, and it is possible to do so, it is Research Laboratories devoted exclu- neutralized by the various organs such sively to the study of cancer at Buffalo, as the liver, otherwise, we would have Boston, St. Louis, New York, Chicago, far more deaths from ordinary blood Pittsburgh and other places at home poisoning than we do. and abroad devoting their whole ener- in like manner the cancer cells are g-ies to the study of cancer. Some day picked up by the lymphatic vessels and they will discover its origin and cure as carried along toward the general cir- well. Por the present we may more culation. When they reach one of the prohtably concern ourselves with the ex- glands (kernels) they are detained for citing causes and treatment. a while ; but finally they break through Cancer is Always Local at First ^"^ ^^'^ poured into the large veins at the root of the neck. Having gotten The most important thing for the into the general circulation, they are laity to understand about cancer is that liable to lodge anywhere in the body it is always a local disease in the begin- that a blood vessel goes, thus, produc- ning. Of course, we have known this ing secondary cancerous nodules (nie- all the while, but it is not generally ac- tastasis). cepted by those who have the disease. Only recently a man came to me with Upon this one fact hinges the cure. I an extensive cancer on the back of his might say it is "the law and the gospel" hand. He said he had had "a wart" on of the treatment of cancer. I can not his hand for two years and that only 134 SOUTHERN MEDICINE AND SURGERY March, 1922 lately had it begun to trouble him. the generative organs or elsewhere must When I went to operate upon him I be considered as indicating a potential remembered two of the facts I have cancer and should be treated according- just been discussing with you, namely: ly. The same thing is true of moles, that cancer always begins locally and warts, birthmarks, chronic irritations, that it gets into the system through lumps in the breast, and abnormal the lymphatics. Therefore, the first growths of any kind situated anywhere, thing I did was to remove the lymphatic Unfortunately, after we have removed glands (kernels) from his axilla. I every visible abnormality, there will knew that if the cancer cells had not still be left enough of internal cancers reached the axillary lymphatic glands that can not be seen, felt or diagnosed, that they had not invaded the patient's certainly in their incipiency, to make body since there was no other way for cancer one of the most terrible of all them to get into his system except diseases. through those glands. Unfortunately, , , . . when we put the excised glands under Cancer and Chronic Irritation the microscope we found them to be j. ■ „ _„i.^.„„ ^^ „^w,rv,^», ^K^^v.„o+,-^r, cancerous Therefore I had the sad ^* ^^ ^ matter of common observation cancerous, inereiore A naa tne saa ^^^ • closely associated with duty 01 tellmg the patient, who was an ^ . irritation. The irritation may Itr hf. liZu.^ ^ifrrJni^ fZ be produced mechanically as by means ther that although I had removed the ^ ^^riction; or chemically, as from the glands and had destroyed with the hot . ^ ^' stomach; or by thermic in- iron every vestige of cancer on the back fl,,_^^„ ^u:„u ^_ V„ „:"iy,„„ u„„t „„ of his hand, the chances were that the !^^h L^^l ''-S.Sf HvnV. Lni tl^v cancer cells had alreadv invaded his ^°^^- ^^ ^^^ constant drop will wear Tor/anTsoone^^M^^er^ould^^^^^^ th^rock;' so a long continued irritation ^pcnndarv cancerous growths pl^pwhere °^ ^^^ tissues of the body will disturb S mh utrwXrhotTron wotear" ^^e relation and growth of the normal ago would have cured that wart, there- '^^^^' «/ .1^''^ „ ^"^ bodies are by preventing the development of the composed The cells begin to mul- cancer. In other words, the best way ^^P^^ with abnormal rapidity. They to prevent a thing is to put a stop to it overlap each other and crowd into the before it happens! That's an Irish bull, '"/•'°""^i,"f ^I'T^' ^^^'^^^ producing chockful of common sense and science a hard infiltrated area or sprout out like too, when applied to cancer. ^ mushroom. In other words, cell growth goes upon a rampage and order Cancers Have a Pre-Cancerous Stage gives place to chaos. This condition is malignant and is called cancer. Not This brings us to the fourth item the being subject to the laws of physiology, laity should know about cancer, namely : which means health, but to the laws of that cancer almost always has a pre- pathology, which means death; it con- cancerous stage. In other words, it is tinues progressively and irresistibly un- something else before it is a cancer, til the patient is destroyed. Take the case just given. It was a wart a few concrete illustrations will indi- for a year or maybe a year and a half, cate the relation between irritation and It was not a cancer during that time, cancer* i j but it was a potential cancer i e. it (^) '^ familiar example is that of the was something that was liable to be- ^j^ ^^^ ^^^ habitually holds a short come a cancer. ^^^^ p^p^ ^^ j^jg mouth, often producing In the Mayo Clinic a large percentage cancer of the lip. The irritation here is of the cancers of the stomach operated ^^echanical from the stem and in part upon are found to be growing upon the , . , ^ ^n ■ j_- a i i site of an ulcer. Before the cancer chemical from the nicotine. A broken started there had been a chronic ulcer or rough tooth may do the same thing which had existed for months, perhaps for the tongue. years. The time then to cure a cancer (b) In India where oxen are gener- is in the ulcer or pre-cancerous stage; ^^j ^^^^ ^^ draft animals, the yoke is or the wart stage, if you please. Hence, ^ , . . , j j. j.-u every chronic ulcer whether it be of fastened to one horn and not upon the the stomach, the lip, the tongue, the neck. Cancer of this horn is common, nipple, or the bowel, every laceration of while it is said never to occur in the March, 1922. ORIGINAL COMMUNICATIONS lis other horn. This is purely mechanical worthy of serious consideration, irritation. During the pre-cancerous stage there (c) In Kashmir, which is a country is no remedy equal to removal of the situated high in the Himalays Moun- growth. This will absolutely prevent tains, where it is very cold, the people the development of cancer. If we can vv-ear a small brazier or kangri basket educate the public, and some doctors as filled with coals of fire underneath their vvell, to the full significance of the im- clothing, next to the skin of the abdo- portance of operating before the cancer men. Cancer of the abdominal wall oc- actually begins, we will cut our cancer curs so frequently among these people statistics half in two. We may go fur- that it is known as the "kangri cancer." ther and state with all confidence that Thus, chronic irritation from heat may even after cancer has developed, and produce cancer. while it is yet local, operation will cure (d) Chinamen are said to eat their at least 25 per cent of the cases and I rice very hot, shoveling it in rapidly verily believe more than that. Hence, with their chopsticks. Cancer of the the importance of two of the proposi- oesophagus, or swallow, among the men tions we have discussed with you ; name- of China is not unusual ; while the wo- ly, that cancer nearly always has a pre- men who first wait upon the men and cancerous stage and when first devel- eat later when the rice is cool do not oped is strictly a local lesion. have cancer of the oesophagus. j,^ the list of remedies the thermo- We do not put the yoke upon the ox's cautery runs the knife a close second, horn, nor wear a brazier filled with live ^y^ g^ould tell the peonle that the coals under our shirt, nor do we all smoke a short stem pipe; but, we do habitually eat our food either too hot or too cold, we have fissures and chronic sores of various kinds, we hold on ten- aciously to moles, warts and lacerations thermo-cautery simply means a hot iron. The poker heated in the fire will cure many a case of cancer. And how simple it is! But, like operations, to be effective, it must be applied while the disease is still local; or what is far our women hide the lumps in their better while it is yet a wart breasts and fail to appreciate the sig- nificance of abnormal discharges having X-rays and radium are double first, cousins. They have much in common; been told by some kindly disposed indo- being the more powerful of the lent doctor that it is the change of life t xt-:..i-„ ,-. „ .<. „ii" „rV,ii« and we all disregard persistent dyspep- two. Neither one is a "cure all" while either will cure a large percentage of tic syniptoms. Thus, we travel along ^ ^.^.i^i cancers, provided, of course, through life unconscious of the fact that l"^f ^u_.- „„„ „^;i, i^.„i a — ^i-^^^c we are carrying a potential around with us all the while, more, we constantly irritate such abnor- mal possessions by ill-fitting dress, im- ^^ ^^^-^^ f^^ ^^^r two years, proper habits, unwholesome diet, the ^^ ^ ^^^ ^f the breast, sar- '''^'^'J^'^':^^'-L^.^j'l!tl?^ coma of the thyroid, as well as many that they are still local. Sometimes I cancer ^^^^ ^jjj ^^^^ ^^^^ seated cancers. They u^ok!!^^ at least nearly always affect them fa- vorably. I have used the X-rays for be aptly called "the match of irritation would be less dangerous. superficial cancers with the X-rays; ....J ...^.^ — in situ. The Cure of Cancer There are only three remedies wor thy of consideration. They are as fol lows: 1. Operation. 2. Thermo-cautery. 3. X-rays and radium. To them may be added the import In radium I feel that we have the most wonderful remedy ever discovered, and I apply it with considerable confi- dence, but, we must temper our enthu- siasm with common sense and results. To my professional brethren who have so kindly and so patiently listened to my story, unvarnished as it is with technicalities and scientific discrimina- tions, I would say, "Go tell in Gath," ance of preventing irritation at every that those who seek may know that point of the body both inside and out. Doctors would call this prophylactic or preventive treatment. It is certainly "The leaves of the Tree of Knowledge are for the healing of the nations!" (Following the address Dr. Long ^'3? SOUTHERN MEDICINE AND SURGERY March, 1922. showed a number of lantern slides and only in those where the increased in- a moving picture gotten up by the tracranial pressure due to hemorrhage American Society for the Control of or cerebral edema is of such a height Cancer, illustrating the development of that the recovery of life and of future cancer and its proper treatment.) normality is more probable by the oper- The Association by resolution unani- ative than by means of the expectant mously endorsed the above paper and palliative method of treatment alone; authorized its publication in the lay in the other two-thirds of these pa- press, tients in whom the increased intracra- nial pressure is not marked, the assist- ance of the expectant palliative method of treatment to the natural means of absorption of the intracranial hemor- BRAIN INJURIES — REMARKS RE- rhage and of the excess cerebrospinal GARDING THE PATHOLOGY, DIAG- fluid will usually prove sufficient— not NOSIS AND TREATMENT. only for the preservation of life but „ „ .„. „, ,, _ ^, „ , ^. also the recovery of apparent normality. By William Sharpe. M. D., New York City. ^j^^ expectant palliative treatment of Interest in conditions of brain sur- these selected patients is frequently gery has been greatly stimulated dur- aided by profuse bleeding and discharge ing the past few years, and is due, of cerebrospinal fluid from the ears or to a large extent, to the frequency of ±roni the nose extrusion of blood and gun-shot and shrapnel cranial injuries cerebrospinal fluid through a fracture in the recent war. In these direct brain of tje vault into the tissues of the scalp injuries involving a more or less exten- to form hematomata of varying size sive destruction and loss of cerebral a"^, m selected patients, by the repeat- tissue, the gross pathology has been ed lumbar punctures of spinal drainage, rather an obvious one— a penetrating so that the intracranial pressure is not wound of the vault with varying de- permitted to rise to a height necessitat- grees of local bony change and, most '^S the cranial operation of decompres- important, the opening of the under- sion and drainage Naturally all de- lying dura with direct cerebral or cere- Pressed fractures of the vault should be bellar destruction; the associated sub- either elevated or removed— whether dural and intracerebral hemorrhage to- an increased mtracramal pressure is gether with the direct cerebral edema present or not— for fear of future com- was the usual cause of the increasing plications of mentality, of the emotional intracranial pressure sufficient to ex- reactions and of epilepsy; if m these trude cerebral tissue. The treatment of depressed fractures, however, there is these acute conditions cannot be de- ^ great increase of the intracranial scribed in detail in this paper and I Pressure, as registered by the ophthal- shall limit my observations to those moscope and especially by the spinal conditions of chronic brain injuries mercurial manometer at lumbar punc- rather than those of war— that is, of t«re, then the operation of elevation or brain injuries associated and unasso- removal of the depressed area of the ciated with fracture of the skull, and vault should be preceded by an ipsolat- especiallv the so-called "fracture of the eral subtemporal decompression to low- base of the skull;" brain injuries re- er this increased intracranial pressure, suiting from depressed fractures of the so that the local operation of elevating vault will only be mentioned. or removing the depressed bone can be The term "chronic brain injury" nat- f ^tlf P^J^°""^f ^"^"^ J^l^^"^^ ^T^^^ urally presupposes a recovery of life ^^ the adjacent and highly developed from the acute condition-whether the cerebral cortex which otherwise might treatment may have been palliative or ^^ extruded and therefore prove a dan- operative. In a large series of these ^^^°"^ ,Tr"'i ?f decompression. In patients, it has become my opinion that "l^f^ ^^ f'?^\^ ^^^% T^u' ^^"^ '^\"'^! the operative treatment is indicated ^^ ^^^ patient would be better without only in about one-third of the cases- fny operation than with this method of local operation alone. Read at the Spartanburg meeting of the Just a word regarding the two stages Tri-State Medical Association, February, 1921. in these acute conditions of brain in- March, 1922. ORIGINAL COMMUNICATIONS 137 jury when no operation should be per- pression for a period of hours and even formed — no matter how badly the skull of days — as indicated clinically by the is fractured nor how large the intracra- blood pressure being definitely increas- nial hemorrhage may be nor how immi- ed above normal and by the pulse — and nent death seems: first, the stage of respiration — rates being irregular and severe initial shock, and second, the retarded to even below 50 and 10, re- stage of medullary edema — the terminal spectively, and then the pulse — and period. If a patient is in a condition of respiration — rates begin to rise rapidly, severe shock following the cranial in- the blood pressure to fall and the tem- jury so that the temperature is sub- perature to ascend (the typical picture normal and the pulse-rate is 110 and of medullary edema and the terminal even higher, in addition to the other stage) , to advise at this late period any signs of shock and particularly that of cranial operation "in the hope of giving lowered blood pressure, then the treat- the patient a chance," cannot be too ment should be limited entirely to the strongly condemned as these patients treatment of the condition of shock; all die with or without an operation — any operation in this period would in fact, any operation performed in this merely be an added shock for the pa- stage of medullary edema merely has- tient to overcome, and if he should sur- tens the exitus. his period of medul- vive, then the recovery is not due to, lary edema can usually be anticipated but rather in spite of, the operation, and even prevented in the treatment of If the patient is unable to survive the brain injuries, either by the expectant shock of the injury itself, surely the palliative method or by the operative additional shock of an operation will method of cranial decompression and not aid him. For this same reason, pro- drainage when the clinical signs— and longed neurological examinations of the especially those revealed by the ophthal- reflexes, fundi, etc., should be post- moscope and by the spinal mercurial poned and all the efforts directed to- manometer— indicate a marked increase ward assisting the patient to survive of the intracranial pressure to such a the shock. When this is accomplished, height that it is doubtful if the expect- then the most careful examinations are ant palliative treatment alone can lower permissible and the appropriate local it. To permit a patient to enter and treatment possible— and the patient's to continue in the stage of medullary chance of recovery is not lessened and compression is running a very great even prevented, it is the general con- risk— either of death or of permanent dition of the patient in this stage of mental and physical impairment. But severe shock that demands immediate if the patient has advanced from the treatment rather than the local condi- stage of medullary compression mto tion, and an important factor in the that of medullary edema with an m- high mortality of brain injuries has creasing pulse— and respiration-rate, no been the neglect in treating this gen- operation is advisable — the patient is eral condition of severe initial shock, not benefited to say the least, and cra- The other important factor in the high nial surgery is merely discredited, mortality of brain injuries has been the In a recent work upon the diagnosis frequent delav and postponement of a and treatment of brain injuries* I real- cranial operation until the natural re- ize now that I did not emphasize suffi- sistance of the patient to a high intra- ciently the relative unimportance (m cranial pressure of hemorrhage or of my opinion) of a definite increase of excess cerebrospinal fluid has been ex- the blood pressure except as indicating hausted during a period of hours (in the lateness of the time for operative those patients having an extreme intra- interference, since this increase of the cranial pressure and particularly when blood pressure is a sign of medullary due to subtentorial hemorrhage) or of compression and the patient should be days and even of two or three weeks given an opportunity to recover by an (in those patients having an increased ^^^^-^^ lowering of the increased intra- intracranial pressure of less severity . , ^:^-v^,. K,r +V,.. r:.vna^+ -, j^ , . , , .<^ - 1 fy cranial pressure, either by the expect- and yet being unable to take care of it sufficiently by the natural means of *"The Diagnosis and Treatment of Brain absorption). If the patient has con- Injuries With and Without Fracture of the tinued in the stage of medullary com- Sif. n«.-n. i? «T5 ,-nfl^tnl fn lithVmeer.fo? Z'Ltl^^J I'^rl tIer^o%llLZfl^^^^^^^ Ztt\TeTe^e^rrLr''^^^^^^ l^n'd^^Vt^^s^cl^y^"^"^^^ -''' ''' ^^^"^^ assures us that the Winston-Salem ana state society. meeting now has every indication of Winston-Salem, April 25-26-27— Rob- being the best and most helpful in the ert E. Lee Hotel, state's history. ^ In addition to the splendid scientific program, there will be much more than usual of important business to come be- fore this meeting. Matters of peculiar and vital importance to the profession of the state and for better service to the ^s one reads obstetric textbooks, an- people of the state. . ^.^^^ ^^ modern, one finds repeated One of the things President Royster again and again the caution to regard has near to his heart is the establish- normal labor as a physiologic function ment of a state journal, and the publi- and to consider interference only in the cation of the papers and proceedings of presence of definite pathologic indica- the meetings in this periodical, thus rele- tions. Recently, however, there has gating to the discard the ancient, expen- seemed to be a change in the way of sive and obsolete custom of having these radical interference even in normal la- appear in book form. bor. Obstetricians in this country ap- Southern Medicine and Surgery in- pear to be aligning themselves definitely sists that no doctor should undertake in two camps — conservatives and rad- to carry the responsibility of minister- icals. At the last session of the Ameri- ing to the lives and health of human can Gynecological Society, opportunity beings unless he joins the march of was given for a statement of the plat- Gynecology and Obstetrics Robert E. Seibels, M. D., Dept. Editor March. 1922. ORIGINAL COMMUNICATIONS 147 ,o™s supported by the opposing P- ^f^f «- j?,— th^^^xrao^^^^ ^^^1* -o J 1 1- 1J7- Tj^irr^^a ^TViP Fads laFgG Humber of cesarean operations, Dr^RudolphW Homes (The Fads | ^^^ practically invariable and Fancies P^ ^^^^^f ^^f^.^T'took the application of forceps merely to hasten & Gynec. 2:225, Sept., 1921) tooK tne ^J Meddlesome mid-wifery has position that the ^.^discrin^mate ^^^^^ dSped from minor transgressions to ployment of ^P^^^^ive inter ve^^^^^^ major surgery. So much for the views obstetrics has accomplished httle m tne J g ^^j^es way of conservation of l^^e of either the °^ ^.^^the'dfs^Son members of the op- mother or the child. He deprecated ^^^^^^ ^^^.^ ^.^^^ ^^ ^.^^^ the ruthless operative course m all par- P^^ ^^ ^^^ent of version, Dr. I. W. turient women as a solution for the p ^^ ^^^ induction of la- troubles incident to the hazards of^^^^^ ^^^ ^^^ ^^^ ^^ ^^g^^ ^^g^^^ t^^^ l^ig He pointed out that very little has been ^^^^ j^^^ j^^ ^^^ ^^^ ^^^^1^^^ contributed in the l^^tfojty years to complications and in a lowered the art of obstetrics. The old masters ^^^^^^^^ ^^^ ^^^^^ mortality. The pro- developed a nicety of technic m tne ^ ^ prophylactic forceps, Dr. J. B. handling of labors which was a guaran- ^Xl onsidedng pituitary solution a tee of excellent outcome in the large -^ .^ ^^^^^^ ^^^ d,. majority of instances, but the death ^^ ^^^ ^^.^^ ^^^^^^ ^j^ ^^Ij^^ ^y^^t rates from eclampsia and placenta prae- ^^^^^^^ ^^^ ^^^^ ^ ^^ undergo the via as complications seem to have been j ^ j^j^ of cesarean section to reduced little If at all Recallmg the ^ .^^ ^^^ .^ ^^ ^^^^ ^^^._ fiasco of the twilight sleep /urore and ^ j^^or He claimed that the powers the dangerous results from thoughtless ^^ ^^^^^^^ ^^^^^ ^^^ dangerous and de- laudation of the reputed harmless vir- ^^^^^^^-^^ -^ ^^any instances to both tues of pituitary solution, D;;- Holmes ^^^^^^ ^^^ ^^.^^ ^^ combines his fre- emphasized that the basic error which application of forceps with episi- has creDt into the obstetric field is the ^^^^^ .^ ^ ^^^^^ He has, however, belief that pregnancy and labor are ^^ gyrnpathy for Potter's podalic ver- nathologic conditions and that child- ^^^^. ^^^^ ^^^ published results bearing is a disease which must be ter- ^^ ^^ mortality condemn the method, minated by some spectacular Procedure. ^^^^^ obstetricians presented pleas for His criticisms are not addressed to the g ^^j^i methods, or cited arguments for general practitioner but to the reputed ^^ against the methods already men- leaders in obstetrics who sponsor inter- ^j^^^^^ ::i^% t^s^-^ oMhis^^le'ss ^ in determining wh^re^ the truth lies operative interference as many of our ^^^^'^fl'f^'fl'^L'lfZl solution as reputed leaders, and they know not the ordinary logic ^^.^ ^^^^^^^ .\^7^^^^ wreck they have wrought for they hear readily in ^h^^^^^^^^^g^^^^^^^^^^^^^ onlv the encomiums of their fallacious ^^o^^^"^-. I TfSclfnrf >fnf IPPrnpTan^^ renresentations and their misapplied g^^ J^.Sg'T/"!^^^^^^ skill. . . . The general Polemic that « ^^ g ^^^ ^^^^ f;uisltioVrre; ^al4n^eTsf /r'e! while there |a tendency to th^^^ .ujntly that many defend most drastic ^vfow rd'tt c^^^^^^^^^^^ interferences on the score of saving ^^^^ j practically always' women this horror-that the dread on ^ ^^^p^ ^^^ ^^ ^^ the part of women of this frightful . ^^^^^^^ ^i^h efficient agony warrants any and all kinds of j^^^^^g ^^^^ ^^^^ expedients to relieve them of the various resm^.^^^ g^^ individualization of stages of labor, when, in fact too often ^^^^^ ^^i^^ts is the sine qua non of suc- hese strictures are merely the shibbo- ^ J ^^^^^^ ^^^ opportunity in eths of those who would operate with .^^^ ^^^ interfere only little or no provocation Among the ^ presence of pathologic conditions practices which Dr. Holmes condemns ^yresenting actual indication for in- are the routine shortening of the first tervention; this has been a true princi- stage by introduction of a bag, the pie of medical practice in the past, and slashing of the parturient canal when it is true today. 148 SOUTHERN MEDICINE AND SURGERY March, 1922. Urology A. J. Crowell, M. D., Dept. Editor Dr. Frank Hinman of San Francisco in an exhaustive analysis of ninety peri- neal and thirty-ei^ht suprapubic pros- tatectomies published in the Journal of Urology December, 1921, says: "that in his hands Young's method of perineal prostatectomy is superior to the Fuller- Freyer method of suprapubic prostatec- tomy. The fatalities have been surpris- ingly few and due in the two instances to avoidable accidents. The functional results even in our earlier cases are un- usually good in view of the advanced and complicated conditions treated. The general results are much better than those obtained suorapubically. No doubt greater experience would materi- ally improve our suprapubic results but we have P'rave doubt of ever being able to so perfect our suprapubic technic as to make it as surgically safe as the peri- neal. If we were to continue doing su- prapubic prostatectomy we would un- hesitatingly adopt as our routine in all cases just as careful and prolonged catheter preparation as for perineal, then preliminary cystotomy, followed bv enucleation after a suitable interval. The perineal method has greater diffi- culties of anatomical approach but our experience proves that they can be mas- tered. The important detail of surgery bv either method in order to be certain of cure, is complete enucleation and good structural restoration. The only doubt of the perineal results in this re- spect is their permanence. The imme- diate results in our last twentv-five cases in which we have practiced radical en masse enucleation, are in everv way satisfactorv. This slight modification in perineal technic gives every assur- ance of complete and regular enuclea- tion which we believe is even more cer- tain and surcrical than possible supra- pubically. The cure, therefore, cannot fail of beine" iust as lasting and perma- nent. Functional results beincr as good or better and as complete, the savin ^ r-mn for hpsitapcv in the reg- istration of our canviction that perineal prostatectomy is worthy of continua- tion in our hands and that its principles and technic are worthy of being taught to others." Our own experience with a modifica- tion of Young's perineal prostatectomy for two years, leads us to believe that the functional results following the re- moval of the gland en masse are better by Young's original operation. Dr. Arthur B. Cecil of Los Angeles reported in the Journal of Urology, De- cember, 1921, one hundred consecutive cases of perineal prostatectomy with two deaths, both of which were hemi- plegics and over 80 years of age. These died of pneumonia on the 14th day after operation. In this series 103 cases presented themselves for treatment for prostatic obstruction. Two deaths occurred dur- ing preliminary treatment, operation was refused on one and 100 perineal prostatectomies were performed. The oldest case operated upon was 90 years and 4 months. The average was 68.7 years. There were eleven cases of malignancy in this series, one of which was so extensive as to produce consid- erable oedema of the left leg. In this paper he brings out the fact that there are certain areas which are more susceptible to certain infections and while others show a relative im- munity to them. He points out the fact that the urethra is very susceptible to Neisserian infection and that the blad- der is seldom infected by it. Tubercu- losis affects the kidneys, ureters and bladder but seldom the urethra. The suprapubic space is immensely more susceptible to infection and absorption than is the perineum and is therefore a biological question which technique cannot change. He justly claims that all cases report- ine- for relief should be reported in de- tail, whether or not they were operated uPon, for statistics to be of real value. This would give a record of the supra- pubic drain fatalities as well as those following catheter drain, continuous or intermittent. He says : "It is to be hoped that this detailed study will be followed by sim- ilar detailed studies on suprapubic pros- tatectomy, for it is only in this way that urologists will be able to reach a proper conclusion ; not as to what is the easier procedure, but as to whether perineal or suprapubic prostatectomy is the path March, 1922. EDITORIAL 149 along which the highly trained special- Dr. Work was called by the President ist should turn his attention." to Washington a year ago to take the He says : "Median perineal prosta- Post of First Assistant to the Postmas- tectomy has not been considered, for it ter General, and the President has pro- is now generally recognized that this moted him to the headship of the de- procedure entirely lacked essentials of partment which has to do with the wel- a proper surgical procedure, both from fare and the happiness of every man a technical and a physiological stand- and woman in the country. Dr. Work point. Statistical studies to be of value, is a graduate of the class of 1885 of the therefore, must give in detail the pre- medical department of the University nrostatectomv mortality rate, operabil- o^ Pennsylvania, and for a good many ity rate, prostatectomy mortality rate years he has been at the head of Wood- and the ultimate functional results ob- ^oj Samtorium, a private institution tained " ^" Pueblo, Colorado, for the treatment Acrfl'in he ^av^- "One rpads of a se- °^ nervous and mental diseases. Dr. Again he says Une reads ot a se g^^vver, the President's private physi- ries of prostatectomy m unselected ^j^^^ ^^.^^ jjj^^^^.j^^ ^^jl^^ ^^ ^^^^j cases. Just what is meant by this is ^^.^^ ^^^ headship of a private sanato- difficult to arrive at for it is evident rium for nervous and mental diseases, that prostatic obstruction in its extreme ^ good manv years ago Dr. Work was deerees causes death, and it necessarily .^gident of the American Medico- follou-s that patients of all degrees of psychological Association and the De- morbidity, as a direct result of prostatic partment Editor still remembers that obstruction, may present themselves -^ ^-^ presidential address Dr. Work re- for treatment. They may be brought in ^^^^^ ^^ heredity as the transmission and die before anything can be done at ^f crystallized environment, all and while it is true that extremely As>ostmaster General Dr. Work will bad risks may, by careful treatment, be have at his disposal much of the choic- successfully operated, there is neces- ^.t political pabulum and it will be in- sanly no such thing as a series of pros- teresting to observe how comfortably tatectomies on unselected cases unless it and philosophically he adjusts himself is a mere coincidence. It could be only to the bedevilments and machinations a coincidence for it is not true that ^f the hungry horde of office-seekers, every case of prostatic obstruction, no ^^^o will pester him by day and break matter in what degree of deterioration, his sleep by night. But in the way of can be cured." self-adjustment and in rising superior Our experience in perineal prostatec- to every situation it will undoubtedly tomy has been about the same as these give him splendid opportunity to prac- men and we heartily endorse their con- tice personally what he has probably elusions. In our last 242 perineal pros- long been preaching to his psychiatric tatectomies, four deaths occurred and patients. we feel this mortality is sufficiently The first installment of "Unpublished chapters from the autobiography of Mark Twain" appears in Harper's Mag- azine for February of this year. The following excerpt is from the prefatory note. "What a wee little part of a per- son's life are his acts and his words! Dr. Hubert Work, lately become by His real life is led in his head and is Presidential appointment Postmaster known to none but himself. All day General in succession to Will Hays, |on?' ^nd every day the mill of his whose resignation became effective 'on bram is grinding, and his thoughts, not March 4, is a physician whose specialty those other things, are his history. His is nervous and mental diseases. Honors acts and his words are merely the visi- have fallen lately upon him rapidly, and ^le thm crust of his world, with its from high place. He is now president scattered snow summits and its vacant . ,, , . ,, ,. , .... wastes of water— and they are so trif- of the American Medical Association, jj^^ ^ ^^^^ ^f his bulk, a mere skin en- as well as Postmaster General of the veloping it. The mass of him is hid- United States. den — it and its volcanic fires that toss Mental and Nervous James K. Hall, M. D., Dept. Editor 150 SOUTHERN MEDICINE AND SURGERY March, 1922. and boil, and never rest, night nor day. Clarence Quinan of San Francisco, con- These are his life, and they are not tributes an article entitled "A Study of written, and cannot be written. Every Sinistrality and muscle co-ordination in day would make a whole book of eighty musicians, iron workers, and others." thousand words — three hundred and For the purpose of study he selects one sixty-five books a year. Biographies are hundred musicians, one hundred ma- but the clothes and buttons of the man chinists, and a hundred inmates of a — the biography of the man himself home for old men. The term sinistral- cannot be written." ity is used to denote a tendency to left- Could the need of psychoanalysis be handedness — for instance, frequent left- more vigorously stated, and the difficul- handedness and the use of the left eye ties of the problem of getting at what as the dominant eye. For the purpose is in a human mind — one's own or an- of testing muscular co-ordination in the other's? two hands a board 10 inches square, which contained 10 parallel rows of This column in the February issue holes of 10 holes each, was made use of. carried a review of an article by Dr. well-fitting pegs were provided, and Pearce Bailey, of New York. About the within a minute's time limit pegs were time the journal reached our readers set from left to right with the right Dr. Bailey lay dead of pneumonia. hand and with the left hand from right For many years he had been recog- to left. It was found that the left hand- nized as a neurologist of outstanding ed set up most pegs in the given time ability, who was especially interested in from right to left ; and the right handed organic nervous diseases. With the en- most from left to right. In this simple trance of the United States into the fashion it was easy to pick out left- or European war he became especially jn- right-handedness, terested in the problem of the mentallv As a result of the experiment Quinan and the neirvously unfit soldier, and found that about 25% of musicians are largely because of his influence a de- at least sinistral — that is they have a partment of neurology and psychiatry tendency to use the left hand by pref- was organized in the army and Dr. erence, and that the percentage of ac- Bailey became its head. Through the tual left-handedness among musicians work that he set going the army med- is surprisingly large, ical service was able to pick out and to Left-handedness is not the result of reject as unfit for service many of the imitation in childhood ; it is not of acci- drafted men. He was steadily promot- dental origin, but it is due to fualty de- ed, and at the close of the war he held velopment of the central nervous sys- the rank of colonel. His knowledge of tem. In the opinion of Quinan the left- mental ineflFiciency caused him to be handed are different also in other re- made chairman of the New York State spects from right-handed individuals. Commission for Mental Defectives, and They are frequently nervous, temoera- in this capacity he was rendering splen- mental, and he looks upon the condition did service to his state at the time of as the manifestation of a psycopathic his death. He had boundless enthusi- make-up. asm, good sound sense, and he was able to get along well with his fellowman. Fondness for reading had brought him into acquaintance with the world's best literature, and he developed an attrac- tive style, and was known as a writer of good short stories and of several Treatment of Otitis Externa With plays. In the domain of neurology and Acriflavine mental abnormalities he was well known The method of treatment employed through his frequent contributions to by J. Coleman Seal, New York (Journal the medical journals. His best work A. M. A., Oct. 1, 1921) consists in first was done probably after he was well cleansing the ear canal with dry cotton beyond fifty. applicators, then packing the canal tightly w^ith gauze 'strips, saturated In Archives of Neurology and Psychi- with 1:1,000 solution of acriflavine, atry for March of the present year being careful not to pack too near the Eye, Ear, Nose and Throat J. p. Matheson, M. D., Dept. Editor March, 1922. EDITORIAL 151 drum. This packing tends to stretch performed without ocular inspection, the canal and permits the antiseptic to and, further, that the tendency in this act on all the micro-organisms in the type of operation is for the nasofrontal crevices and fissures. The patient is sup- canal to narrow or close up, is sufficient plied with some of the solution and in- to recommend the combined internal structed to keep the packing moist by and external method of Lothrop in the use of a medicine dropper. This place of it. The objections to the Loth- procedure is repeated every twenty-four rop operation would appear to be large- hours, until the ear canal is completely ly theoretical, patulous and free from infection and Orthopaedics Alonzo Myers, M. D., Dept. Editor pair. One week is the usual length of t'me required to clear up an infection. In cases in which definite furuncles have formed or are forming, when the packing is removed, the furuncles will be found to have opened themselves and the pus to have been absorbed by the gone Operations ^^"^^- At the Tri-State Medical Meeting, held February the 22nd, 1922, at Nor- CauFes of Failure in Radical Operation folk, Va., Dr. F. H. Albee of New York on Frontal Sinus gave a lengthy paper— moving pictures . , . , , rr^^^^„ T — and a discussion on rehabilitation. I An endeavor is made by Thomas J. ^^.^^ particularly interested in what he ?YT'1^SY^^.'''■'' ^^"'';2 • V said of "Certain Fundamental Laws Oc . 8, 192 ) to explam the causes of ^mderlying Surgical Use of the Bone failures in the frontal sinus operation, q^^^^ ,; ^ How to avoid sucli failures is not di- ^ " ^, , . ,, rectly a part of the paper; but a brief The author enumerates various meth- consideration of it follows. The em- ods which are being used for the treat- plovment of proper technic in the op- ["ent of pseudarthrosis such as in.iec- eration on the frontal sinus should be tion of blood into the site of the lesion, undertaken until satisfactory roentgen- Bier s hyperaemia, deep massage to ograms have been taken and carefully promote healthy circulation, and fixa- studied. In the great maioritv of small tion of the fragments by means of metal sinuses the pathologic condition resolves aPPl'ances During the past twelve itself whatever operation is performed, years he has studied many cases in provided all diseased tissue is removed, ^^hich one or more of the above forms The object in any operation should be o^ treatment have been carried out either the obliteration of the sinus af- and as a result, he believes that all ter complete exenteration of its contents f.^^h non-operative procedures,_and par- or the establishment of permanent ocularly operative methods involvmg drainage and ventilation after removal the introduction of metal, have no place of all diseased contents. When it has i" the consideration of the proper treat- to do with large sinuses, especiallv with "^^nt of pseudarthrosis. _ marked orbital projections, it is a ques- The bone graft operation is the only tion whether complete obliteration by method offering a solution of the prob- the Killian method is possible. The im- lem, and the inlay technique is the most nortance of giving particular attention trustworthy one. In order that the to the cureting of the external and in- fundamental laws pertaining to tissue ternal angles of the sinus, is empha- transplantation be fulfilled, the graft sized. The fact that in a great major- must consist of all four layers, namely, ity of sinuses the diseased condition re- periosteum, compact bone, endosteum solves when the floor of the sinus has and marrow. not been removed would indicate that The osteoperiosteal graft fails be- removal of the floor, as recommended in cause of its lack of rigid continuity, and the Killian operation, is not necessary, is, therefore, incapable of furnishing Much is to be said in favor of procedures fixation. By nature of its removal it which tend to secure drainage and ven- cannot be a complete osteo^-enetic unit, tilation rather than obliteration. While Since it does not nossgss ris-id continu- the intranasal method has been much ity, and is, therefore incapable of bear- recommended, the fact that it must be ing mechanical stress, its metabolism 152 SOUTHERN MEDICINE AND SURGERY March, 1922. and bone growth are not influenced by 2. It is impossible to distinguish be- that powerful stimulus of withstanding tween lesions of the eighth nerve itself mechanical stress without fracturing. In and the labyrinth. place of the osteoperiosteal graft the 3^ Lesions in the posterior cranial author uses his so-called "silver graft" fogga which either compress or invade which consists of a thm slice of bone the brain stems may cause modification containing all layers. of the normal ear responses. Usually The author advises that before decid- there is absence of or diminution of re- ing to operate on cases of pseudarthro- spouses to stimulation of the vertical sis, one should resort to rough manipu- canals with good or perverted responses lation of the fragments, deep massage, from the horizontal canal. Perhaps the possilily a two-stage operation, in order most definite finding so far is in tumors to avoid a recrudescence in cases which of the cerebello-pontile angle, growing have been infected. Other points which from the eighth nerve. These are: to- are essential to success are that the op- tal absence of all response from the eration should be of short duration and eighth nerve of the aflfected side with no that the operator should plan his in- response of the vertical canals from the cision through the skin so that it does opposite side, leaving the horizontal ca- not overlie the bed of the graft. The nal on the opposite side the only func- graft should be long enough if possible tioning one. to extend into each fragment for a dis- 4. in lesions of the cerebellum there tance of five cm., and it should always is nearly always absence or marked extend beyond the eburnated end of the diminution of vertigo on stimulation, fragments. The graft should be held in _ , ,.„ ^. ^. place by absorbable sutures. , ^; In diflferentiating between supra- ^ tentorial and mfratentorial lesions, the The author emphasizes the imoor- presence of normal i»esponses from both tance of post-operative fixation and he labyrinths strongly indicates a supra- advocates a plaster of Paris soica in or- tentorial lesion. der to immobilize both shoulder and el- t ^u j- ' • ^ i.i_- -^ u bow. He uses absorbable skin sutures ^" *^^ discussion of this paper it be- to avoid disturbance of fixation. came evident that certain leaders of neurological thought held to the con- ception of a cortical vestibular center, Dr. Mills of Philadelphia being espe- cially emphatic in this belief. Dr. Gush- ing of Boston referred to his own ex- perience with temporal lobe lesions in Vertigo is a symptom which often which he had often found definite nys- presents as the major comolaint of the tagmus, vertigo and inco-ordination, patient, and not at all infrequently it ^nd stated that it was often almost im- may be the sole svmntom of which the -ui u ^ i.- ^ ^ n ^1 i-^ patient complains. It is orobable that J^^^^^^^ ^^^^^^ ^P^^f ^°" ^° tell the dif- manv cases with this comnlaint are Terence between' what proved to be a rever subjected to the searching inves- temporal lobe lesion and a cerebellar tigation for cause which modern re- lesion. search has made oossible. The value A/i,>,;ff;v,^ +v,o.(- ;« 4-v,^ ^,,«„^„4- +„4-„ ^.-? +1 „ T>„^ , , J. i.-!, 1 ^ Admitting that m the present state <>f the Barany tests of vestibular func- » 1. • , j , • , • 1 tion is now widelv recognized. °^ «"^ anatomical and physiological We^-senburg of Philadelphia has sum- knowledge of the equilibratory mech- marized in a oaoer read before the 47th anism, a considerable element of uncer- Annual Meetiner of the American Neu- tainty may exist in the differentiation rological Association conclusions which of various causes of vertigo, it is very he regards as obvious and legitimate obvious that this symptom, whether ex- with reference to these tests as follows : . ^. , . . 1 1 rm, 1 J! ^ . . istmg alone or as part of a complex, 1. The value of ear tests in pure ,, „ ,. , . , • ^. , ,, ioi,vvtpt%,-.. fi,>pp,p as distinguished ^^"^ ^^^ ^ ^^^^^"^ investigation by all from cerebellar disease is bsyond ques- -mailable means, and among these the tion, Barany tests are of great importance. Neurology R. F. Leinbacb, M. D., Dept. Editor March, 1922. EDITORIAL 15S Roentgenology FT. Lafferty, M. D., Dept. Eflitor The meeting of the Eastern Section of the American Roentgen Ray Society at Atlantic City January 26, 27 and 28, was one of the best meetings that this section has ever had. The effort was successfully made to bring the clinical men and the roentgenologist together. The three outstanding clinical men on the program were Drs. Baker, Timme and Blake. Dr. P. M. Hickey of Detroit, recently elected to the Professorship of Roentgenology at University of Michi- gan to succeed the lamented Dr. Van Zwaluwenburg, presented a very timely paper on the "Standardization of X-ray Reports." Dunham gave a splendid pa- per on the "Study of the Abnormal Densities as an Aid to the Prognosis in Pulmonary Tuberculosis." Dr. James Ewing i)resented a most wonderful pa- per on "The Standard Reactions of Nor- mal and Cancer Cells to Radiation." The physical papers were also of a very high order from such men as Shearer and Duane. The following review of an article by Dr. Mary E. Hanks on "The Roentgen Ray in Uterine Fibroids," which ap- peared in the P'ebruary issue, 1922, of the Journal of Radiology will be of in- terest to many. Dr. Hanks cites facts to show the similarity between the changes attend- ing the normal menopause and those at- tending the artificial X-ray menopause. Edema of the endothelial lining of the capillaries is produced ; ovarian stimu- lation is inhibited, and ripe and ripen- ing graafian follicles being first affected, then the primodial follicles and last the interstitial tissue. If all follicles are destroyed amenorrhea will persist and the uterus will atrophy. The internal secretions of the ovary are not inter- fered with at all. The interstitial tis- sue of the ovary is the last to be affect- ed and probably escapes with full func- tioning powers. It is an important source of ovarian endocrines. The risks of failure in roentgen ray treatment of properly selected cases is 80 small as to be negligible. The size of the tumors treated varies from the very small to that the size of a full term pregnancy. The indurated, non-vascular, fibrous tumor with no history of hemorrhage recedes slowly and gives least satisfactory results. The most favorable age is forty years or older. That certain associated pathology is a contra-indication to X-ray is not true as the author's experience proves. Prompt healing in cases of erosion of the cervix uteri has taken place under roentgen ray treatment. Follicular cysts have been much improved. X-ray reduces the typical fibroid but never re- duces the large ovarian tumor. Hem- orrhage has been controlled in ninety- nine per cent of the cases. The importance of an examination exactly locating the tumor and estimat- ing the pelvic condition in general is primary. There must be thorough sys- tematic raying beyond the time when menstruation ceases. Twelve series ex- tending over two years is the most the author has given. The average oper ator is too casual in his diagnosis, tech- nique and general conduct of the case, especially in his estimation of end-re- sults. A follow-up system is essential for best results. The author's first thirty consecutive cases show today fully eighty per cent without demonstrable tumors. The great majority of those who still have demonstrable tumors are "symptomat- ically cured," i. e., the patient is not conscious of its presence, it is freely moveable and the menopause is estab- lished. Of the remaining cases two very large tumors have been much reduced in size and symptoms very largely rem- edied. One case had to be operated be- cause of gonorrheal infection. One case had a myxomyoma and is interest- ing because conception took place after X-ray treatment. One case has died of heart disease, two discontinued treat- ment too soon, two cannot be traced and three are still problematical. No case has developed malignancy. The fear of sarcomatous transformation is not based on logical reasoning and au- thority is cited to support this view. The technique employed is the cross fire method, using the Coolidge tube, nine-inch spark gap, seven-inch skin dis- tance, five milliamperes and four to 154 . SOUTHERN MEDICINE AND SURGERY March, 1922. News Items seven-minute exposure. One large sin- gle does is not favored by the author. Deviations at the lumbo-sacral and the sacro-iliac joints were present in many of the eases treated and the au- thor is inclined to consider that this Clinical Congress of American College may be an etiological factor and con- of Surgeons, North and South vinced that recovery is slower and some Carolina Sections iSfe'r'^ncr'" ''^''' ^''^'''' '^ ^^'' A joint meeting of the North Caro- X-ray has been preferred to radium ^f ^ ^."^ South Carolina Sections of the because it works more slowly, reduces ^T7V^\" ^^°"T / P^^^f ^Z r^^^^^^ the large tumors more successfully, and ^e^^ at Asheville, N. C. in the Conven- can be applied without loss of tim^, in- ^lon Hall of the Battery Park Hotel, convenience or discomfort — also the ^, ' ^)'^'^' n j i. o ^ danger is negative from roentgen rays. ^ The meetmg will be called at 2 pm. Intra-uterine application of radium ^Y Dr. C W. Kollock, Charleston, Chair- may produce serious results. ^^P- ^he program includes: Thousands of women are still under- . ^^^P°'P^^/l^'^^LT''°Li\H H going operation without being offered JS^rtSM^Di^eftor Genera? A^ the information to which they are en- Martin, M. U., Director (general, Amer- titled about the roentgen ray' '"^"l.^^^ tP .""^ ^""l^^T- -, , o "The Work of the Hospital Survey- Hospital and Sanatorium John Q. Myers, M. D., Dept. Editor or," Mr. T. E. Allen. "Hospital Standardization from the Surgeon's Standpoint," John Osborn Polak, M. D., Brooklyn, New York. "Hospital Standardization from the After a careful survey of the North Patient's Standpoint," Mr. R. I. Ray- Carolina hospitals, it appears that the mond, American College of Surgeons, much talked of question, "Nusring," "Hospital Standardization from the should be settled by the North Carolina Hospital Superintendent's Standpoint," Hospital Association rather than the J. Warren Knapp, M. D., Superintend- Nurses' Association. In the language ent. Watts Hospital, Durham, of one of North Carolina's most promi- "The Soul of Hospital Standardiza- nent doctors, surgeons, and hospital tion," Rev. C. B. Moulinier, S. J., Presi- men. "I think the finished product is dent. Catholic Hospital Association, attempting to dictate to the factory (the Discussion : Opened by H. A. Roys- hospitals) that makes the product, how ter, M. D., Raleigh; Joseph C. Blood- to-do it." "The Hospitals and Surgeons ^^o^' ^- ^^ Baltimore, Md. are^a lot of weaklings if they continue Arkansas Medical Society to tolerate this condition." ''^ome day ^^.^^ ^^ Secretary-Editor they will wake up and find that strong kittle Rock, March 1, 1922. as they are, (the ex-president of the ^^^^ Editor- Hospital Association) they have been ^he motif 'of our coming annual ses- bound hand and foot with the hair of a gion to be held in Little Rock, May 17- woman's head." 18-19 next, is to be the "home coming The nursing situation, so far as the ^!f ^"?" ^^^ T^%^^^ ^"^ desirous of , ., , , ' . ^ , informing our old time doctors from Ar- hospitals are concerned, is soon to be kansas, now practicing in other states, the burden which the people can't stand, and stressing the fact that we shall ex- Three graduate nurses (eight hour pect them to be with us at the time indi- duty, as some would like to have it) for cated. This will be especially appHca- a serious surgical case, at the cost of b^e to those desiring to attend the meet- +„r 4- /(EOAAAN A ^^ J ,2. ^^^ ^^ ^he American Medical Associ- twenty ($20.00) dollars per day, can't ^tion, at St. Louis; as they can stop off be paid if the hospital and surgeon gets with us, renew old acquaintances and a fee. resume their journey. March. 1982. EDITORIAL 155 We shall appreciate it very much if Dr. Andrew C. Fisher, Emmerton, you will carry a suitable news item in Va. ; Medical College of Virginia, Rich- your journal/setting forth our good in- mond, 1885; member of the Medical So- tentions, that those in your state may ciety of Virginia; died February 7, be reminded of the invitation extended from pneumonia. to them. This may seem unique; but in the ever changing present the unexpect- Dr. Frederick Robt. Farthing, Boone, ed happens daily. Therefore, we are N. C. ; Jefferson Medical College, Phila- relying on the co-operation and active delphia, 1921; died February 14, aged assistance of our friends in putting the 27, from pneumonia, at St. Joseph's meeting over. Hospital. Thanking you in advance for any — courtesy you may be able to extend us Dr. James Wm Flowe Kannapolis, and trusting that we mav have a visit ^•^ ^j \ r^^^^^^^^'^^'"^^^"^^'^^ ^^""^!,' from vou along with the others, we are, Charlotte, 1898 ; died February 8, aged ' -, ^ ,. ,, 44, trom chronic nephritis. Most cordially yours, __J___ Wm. R. BATHURST, Dj. Edgar R. Pole, Hot Springs, Va. ; Secretar>'-Editor. ^^as married to Mrs. Alice Clarke, of Charlottesville, Va., in January. Richmond Academy of Medicine At the regular meeting of the Rich- Dr. J W. Babcock. Columbia, S. C, mond Academy of Medicine and Sur- 'necologist Dr. George Roberts, Alexandria. Va. ; to operate, if avoidable, and of the be- University of Pennsylvania. Philadel- neficent effects of ductless glandular phia, 1868; died February 1, from sen- therapy in certain conditions once jiity, aged 75. thought to indicate pelvic operation. " The Lincoln Hospital, for negro pa- The Virginia General Assembly has tients, Durham, which was totally de- recently by a substantial vote disap- stroyed by fire, January 26, at an esti- proved of the plan to merge the Medical mated loss of $15,000, will be rebuilt at College of Virginia with the Medical a cost of $100,000. funds for which have Department of the University of Vir- already been raised. ginia. with the removal of the latter to Richmond. The two schools are left to Dr. Albert S. Root, Raleigh, has been function separately, as they have been elected president of the Wake County doing heretofore. Medical Society. 166 SOUTHERN MEDICINE AND SURGERY March, 1922. Dr. Arthur Blake Clarke, Planters- Doctor Taliaferro discussed at some ville, S. C. ; University of Maryland length the remarks attributed to Dr. School of Medicine, Baltimore, 1906; John B. Deaver at the recent meeting died January 31, from lobar pneumonia, of the American College of Surgeons in aged 51. Philadelphia, disagreeing with Dr. Deaver. Dr. Clyde K. Hasley, radium and Dr. J. L. Rawls: I doubt if radium roentgen-ray therapy specialist in the has any selective action on cancer cells. Crowell Clinic, Charlotte, has been ap- I believe it is because they are nearer pointed associate professor in the Uni- the embryonic state that they are de- versity of Michigan Medical School, Ann stroyed and the surrounding tissue not Arbor. injured. I believe if we adopted the routine use of radium in all cases of car- Norfolk County Medical Society cinoma of the cervix, our mortality The section on Surgery and Gynec- ^<^JJ^^ ^^ J^^^j. . , , , , ,. ... ology of the Norfolk County Medical , »r- ^'\ Hirschler: I believe that Society held its regular monthly meet- ^^^.^^^f ^^1 usefulness of radium lies ing Monday evening, January 9, 1922, m the fact that it may be readily applied Dr. R. L. Payne in the chair. to places not easily reached by surgery. Dr. E. C. S. Taliaferro read a paper "r. L. Gwathmey: At the Philadel- on "The Use and Abuse of Radium." phia meeting practically all the men as- Radium is recognized as being superior sociated with Dr. Deaver deplored his to all other forms of treatment in a remarks in regard to radium because definite group of lesions, especially in they were sure they would be misunder- skin cancers, notably in basal-cell or ftood. Dr. Burnham believes radium non-metastisizing carcinomata. These t}ie method of choice in carcinoma ot should be recognized early, not only by the face and tongue. Our own experi- the specialist but the general practi- ence supports this view. Radium is dan- tioner, that the patient may be referred gerous if used m inadequate doses. We for treatment at an early stage; for it are just beginning to appreciate the ap- is in the early stages that radium does plicability of radmm. .^, . . the most good. Dr. E. C. S. Taliaferro : (Closing) It is recognized by all authorities that We have several cases of fibroids cured radium is "the" form of treatment for by radium, but I believe they should be all the different types of lukemia. removed if possible. In the treatment Radium has perhaps its greatest of carcinoma of the cervix I believe we sphere of usefulness in the field of should use both radium and X-ray. Gynecology, not only in malignant con- I^r. Fov Vann read a paper on "The ditions but also in fibroids in which the Modern Treatment of Fractures." patient has some heart or kidney lesion Modern fracture treatment is physio- contraindicating surgical interference, logic treatment; treatment by preserv- These cases show marked improvement ing instead of restoring function. The on radium therapy. It is also useful in method of treatment is important, but menorrhagea and metorrhagea in both what one wants to know is the length types of old and young. of disability and the ultimate effect on The use of radium is also advocated the patient, in carcinoma of the cervix, three or There are two agencies of major im- four treatments ten days apart in con- portance in the treatment of fracutres junction with deep, intensive X-ray ex- of the femur and leg; Thomas splint posure through the pelvis. The author and plaster of paris. The less the has probably operated on his last case Thomas splint is modified the more ef- of carcinoma of the cervix. ficient it is. For fractures of the neck Since radium can be applied without of the femur, as perfected by Whitman, pain or discomfort and since it confines and for fractures below the knee, plas- the patient to the hospital for but a ter of paris is usually indicated. For short time, all cases suspected of ma- fractures of the shaft of the femur, the lignancy should be treated with it rath- Thomas traction splint has shown itself er than wait until the condition is so to be far more useful, both as an emer- far developed that both surgery and ra- gency splint and as a splint for contin- dium would probably fail. uous treatment, than any and all other March, 1922. EDITORIAL 157 mechanical devices heretofore recom- mended for the purpose. Skeletal trac- tion for fractures of the lower thigh or leg and for femur over-lappings is an important addition to the splint. The Balkan frame is a valuable addition, es- pecially for extensive and compound in- juries to the thigh. Mole skin plaster or adhesive glue is used for traction because it is intrinsic in the splint. Ele- vation of the foot of the bed contributes to the traction and simplifies the wear- ing of the ring. The elimination of Buck's extension, Ruth-Maxwell method, Volkman splint, Liston splint, and similar and related methods from the text books would hasten the elimina- tion of confusion. For infants and children the plaster is preferable as traction is not so imperative. If the foot is inclined in the plaster and an- chored, the child slides upward in the dressing supplying this traction, but in a reverse manner. Dr. J. H. Culpepper: The correct treatment of fractures is by the phy- siological method as Dr. Vann has de- scribed. Recently in treating fractures of the thigh I have used ice-tong exten- sion and have gotten good results. In this way there is no impairment of mo- tion in adjacent joints. Proceedings of Obstetrical Section, Nor- folk County Medical Society, Janu- ary 23, 1922. Dr. Burnley Lankford showed a child, six months old, presenting on the cra- nium two areas of excessive bone for- mation, one on left parietal bone, the other at the post, occipital protuber- ance. History, briefly was as follows: Was first child, mother was healthy, vigorous woman of 31, having had a normal pregnancy throughout. Labor lasted 19 hours, was terminated spon- taneously, head was on the perineum rather longer than usual because of stout outlet muscles, a central episio- tomy having been done eventually. Child presented no abnormality at birth. About twenty-four hours after birth a tumor began to form over the left pa- rietal bone, (posterior portion), which continued to enlarge for several days, finally becoming 7 cm. long, 3 wide and approximately 3 thick. At the end of 48 hours after birth a second tumor be- gan to form over the occipital region which reached its greatest size in about two days and was approximately 3 cm. in all directions. The diagnosis was as between cephal- hematoma, caput succadaneum, and meingocele. The tumors were fluctu- ating so caput could be ruled out : they did not become more tense on making the infant cry lustily, so meningocele was ruled out. Other points in estab- lishing diagnosis of hematoma, were: the skin over the areas did not become discolored, as would have been the case with caput : the tumors were not pres- ent at birth, as would have been the case with caput : they continued to enlarge for several days, after birth, as would not have been the case with caput: they were never apparently tender, a caput often is. The peculiar outcome of the hematomas is the reason for pre- senting the case. After about ten days, the skin over the tumors began to have a parchment like feel, which is not un- usual, but as time went on, this parch- ment like condition became thicker and harder, until within two weeks the whole tumor masses had become solid bone, as hard as any part of the cra- nium. These masses are now approxi- mately half the size they were shortly after birth. The child apparently is normally developed in every respect. However, the masses caused a great deal of concern to the parents and fam- ily and brought Dr. Lankford somewhat into disrepute, because he had prom- ised the fond grandparents, parents, etc., that the tumors would soon vanish of their own accord and would need no further treatment than compression bandages, which were used, without ap- preciable effect. The question now raised is the ap- parent mistake in the let alone treat- ment of cephalhematoma, which is ad- vised in every textbook to which Dr. Lankford has had access, all of them saying that nothing should be done ex- cept in the presence of suppuration. Dr. Lankford is of the opinion that all such cases should be treated by aspiration by trocar, after the tumor has reached its growth. Such aspiration being done under conditions of surgical cleanli- ness, can do no harm and may be the means of avoiding such a troublesome and embarrassing outcome as in the case presented. The only explanation to be given of the bone formation in the 158 SOUTHERN MEDICINE AND SURGERY March, 1922. hematoma is that the hemorrhage takes in 30 minutes after birth of fetus, show- place under the pericranium, lifts it off ed following: At one place on peri- the bone and with it goes the osteoge- phery of maternal surface, an old, black, netic layer of the pericranium, which adherent blood clot, which when shelled begins soon to throw out new bone, out left a "nest" with a hardened, thick- causing the parchment like feel, and ened border, nest being 4x6 cm. This which new bone formation goes on un- hemorrhage evidently took place Dec. til it comes in contact with the under- 31, when she began to show symptoms; lying skull bone. Dr. Lankford report- not sufficient, however, to interfere ed one such cephalhemota, occurring in with the existence of the fetus. On the his practice since the case shown to- fetal surface of the placenta was found night, treated by aspiration with trocar, the pathology that accounted for the with perfect results. sudden death of the fetus. A fan- Apoplexy of Placenta shaped area, taking in one-half of the Dr. Lankford presented a fresh pla- entire fetal surface showed discolora- centa, having been delivered three days ^lon due to hemorrhage The handle before. Following history : Mother, «{ the fan extended up into the cord for two para, previous pregnancy, labor, about 1 cm., where fresh blood could be etc., presenting nothing unusual. La- seen loose m the cord jelly, under the bor due January 25. Dec. 31 patient membranes This blood was extra- complained of some pain and feeling of vasated into the substance of the pla- discomfort in left lower abdomen, ac- centa throughout its entire thickness, companied by uterine contractions, the change in color and consistency be- Uterus soft between pains. No bleed- '^S quite plain on both the fetal and ing externally and not enough to diag- maternal surfaces. It seems to be due nose premature separation, with con- to the rupture of one of the umbilical cealed bleeding. Pressure was found to vessels and as exactly one-half of the be 120 over 80, which seemed normal. Placenta is involved, and as the apex of However, this patient had been known the triangular area, is in the cord, it to have had a pressure all through preg- wo"ld seem that one of the umbilical nancy around 100, so that the rise to arteries ruptured shortly before birth 120 was significant. Specimen of urine ^^ ^^^ ^^^us As to the cause of the that had been albumen free, now show- ruptiire, and of the older hemorrhage ed 1% bv Esbach test. Next dav no on the maternal surface, that is a horse pain'but\ feeling of discomfort^ was of another color. Most cases showing still present, pressure had risen to 140; such placental conditions, also show al- albumen from 24 hour specimen showed bummuria and other evidences of ne- (Esbach) 1/,%. The next day pressure Phritis, (this woman showed a few had risen t3'l60, despite absolute rest f^anular casts, pale, low gravity urme) in bed, mild diet, magnesium citrate, l]"^ consensus of opmion, it seems at She was taken to hospital with intention ^^^ P^^f,^^ \^ *^^^. the same underlying of inducing labor. Fundus was 29 cm. F^ause of the toxemia, whetever that may above symphysis, fetal movements vig- ^^.' (whether of liver or placental or- orous, and nothing about heart to cause '^'"ll'^ ?^ ^^T °^ ^""^^ *^^ nephritis alarm. Condition in hospital gradually ^"^ ^^^ hemorrhages, became better so that labor was not in- Dr. George Schenck read a paper on duced. Patient remained in bed, under "Extra-Uterine Pregnancy," laying par- daily observation, until the 20th, when ticular emphasis upon the best method she went into labor spontaneously, and ^f dealing with the placenta, in cases delivered herself of a dead fetus. Born of abdominal pregnancy. The consen- at 11:40 a. m. At 11 a. m. the fetal sus of opinion was to leave the placenta heart was heard, strong, regular, L. L. within the abdomen, when attached to Q., 126, (same at 9 and 10 a. m.) . When the intestines, after removal of the cord head was born, cord once around neck ^^ elose as possible to its insertion, clos- was not pulsating. Delivered easily at i^g the abdomen without draingae. Re- once. No heart beat was ever seen, felt viewing the literature Dr. Schenck or heard, no effort at respiration ever found that tubal pregnancy occurs in made, though efforts at resuscitation ^^^^ -8% to 1% of all pregnancies, and were persisted in for one hour and 20 reported from the literature more than minutes. The placenta, delivered easily 20 cases of abdominal and ovarian March, 1922. EDITORIAL 169 sac. pregnancies, primarj- in origin. Kelly Fortunately, we find roses scattered reported 77 cases of extra-uterine preg- along our pathway to cheer and encour- nancy delivered by laparotomy, from age us in our labors, in the way of ap- 1809 to 1896, 35 infants died within 50 preciation and gratitude. Something hours of birth, 7 lived for one year or like a year ago I attended a woman in more. To justify a diagnosis of ovarian confinement, and after all was over I pregnancy the following criteria must went out to get into my car (ten miles be present: The tube on the affected in the country); the husband asked if side must be intact: The fetal sac must we liked fresh meat to eat, and, of occupy the position of the ovary : it must course, I did not deny that we did. He be connected with the uterus by the took me to his smokehouse and threw ovarian ligament: definite ovarian tis- open the door and told me to pick out a sue must be found in the walls of the piece. Nothing but hams and shoul- ders. I hesitated, and he picked up an B. E. Harrell, Reporter. 18-pound shoulder and said, "Take that home and tell your wife to cook that for dinner." He already had given me Specialism vs. Country Doctor ^ check for my fee, $25.00. I told him By J. R. Smith, M.D., Warsaw, Mo. that spelled gratitude in big red letters (Medical world. Feb.. 1922.) ^0 me. He said, "We are more than satisfied." What constitutes a specialist? Spe- ^^^ shouldn't make a success if he cial study, special equipment and espe- ^^^ ^^^^^ ^^^ ^^^^^ ^^ ^.^^^^^^ ^^ ^^^^^ cial nerve in rendering the bills, prin- ^^^ ^^^^^^ ^^^ ^^^^, ^^^^^^ ^^ ^^^^.^^ cipally, cash or no trade. In other ^^^^ ^.^^ ^^^^ compared to the little words, "moneymania. Like the saloon ^_^^^_^ country doctor, as he is classed and whiskey drug store, he has gone ^^^ specialist when the latter deliv- into the business because there are ^^^ ^^^ ^^^^^ .^ ^ ^^^ ^^.^^^ ^^^^ ^^ ^^^_ higher fees and less work. Show me ^^j^^^^^ ^,^^^ ^^^^ ^.^^^ ^^^ ^^.^ater the specialist who does more heroic and ^^.^^ ^^^^ .^ required by the specialist life-saving work than the ordinary f am- .^ ^^^^ ^^ ^.^ ^^^^g, ^j^^^ then, is ily physician, who gets up and goes at ^^^ specialist? The man who is pre- all times of night and all kinds of ^^^^^ ^^ ^^^^ ^^^ ^^.^^^^j^ ^f ^jige^se in weather to alleviate sickness and suf- ^ g^^igntific way, or the man who is com- fering, who actually prevents death en- ^^jj^^ ^^ ^^ prepared to meet even the tering the home by using antidotes to jj^possible? To be capable of recogniz- poisons that would destroy life if not ^^^ conditions that mean positive death counteracted, who brings health and j^ ^^^^ ^^^^^^ ^^^.y. ^^ surgical opera- happiness when the child is born, who ^j^^ j^ ^ot performed at once, where the supplies the remedy to combat the con- specialist is called in, and who carries tagious disease that threatens the lives ^^ ^^le jewelled crown which we will of the little ones (diphtheria, scarlet g^^^^t he deserves, and yet who was the fever, spinal meningitis, and the innu- protector of that life, the one who per- merable affections), who acts as the foj-^ed the operation or the one who family counsellor, the protector, and the recognized the dangerous condition in most-trusted one in the home, who is ^j^^ ^^d called in assistance to prevent given the highest honors with the least ^^^^^^^ j^^^, ^^^ .^ ^ ^^^^^^^ ^p^. pay of any professional man in any . ,. , ^, . ., , . . o « ij J • i-iT .c 1 -.CL- i.u u cialist than the family physician? field, and in the final sifting the one who ^'**"°'' j *- j is least appreciated and the poorest paid Every disease requires special study, for the ability and service rendered. special treatment, special degree of ed- 160 SOUTHERN MEDICINE AND SURGERY March, 1922. ucation, to differentiate the dangerous "Eat-More" Campaigns conditions from those that are not seri- -p^is is the day of the "Eat-More" ous, the malignant from the non-malig- campaign. From billboards, newspaper nant diseases. Whose education, then, advertisements and periodical pages, requires the most complete prepared- the slogan "Eat-More" crashes upon the .^ reader s mtelligence. He is besought to "^^''^ ■ eat more meat ; he is requested to eat more raisins; it is hoped that he will ^ , „„ ^- eat more oranges; he is invited to eat When to Operate and When to Use ^^^.^ applies; the coffee planters beg Radium on Fibroids of the Uterus him to drink more coffee; the tea im- The prnicipal field for radiotherapy porters beseech him to imbibe more George Gellhorn, St. Louis (Journal A. tea, and the tobacco manufacturers M A Tan 28 1922) sav^ is • (1) in P^^^^ ^°^ purchase m carton rather M. A., Jan z», ly^Zj, says is. U^ in ^^^^ .^ individual package. And when- women of 40, or over, who have fibroids g^g^, possible the earnest advertiser which do not extend above the umbili- drags in a medical argument to sustain cus ; the more uniform the enlargement his plea. Without reference to the ac- of the uterus, the better is the case suit- tual justice or injustice of any of this ^ -p +!,;„ ^-^^^^- v,+ . /o\ ,„^vv,^v, „,u^ advertising, it is well to bear in mmd ed for this treatment (2) women who .-, . i. \ n i-, j- i u • ' ^ ' . , . , that greatest of all medical aphorisms : are designated as poor surgical risks, -Moderation in all things." that is, patients with marked secondary anemia; (3) those who are opposed to any form of surgical treatment. Radio- ^""^^ »"d Development of Drug Therapy therapy is indicated in women above the A general survey of treatment as it age of 40 who have symptomless exists today is made by L. G. Rowntree, fibroids. In the hands of the expert, 5°f^^^^,!fA, J^^"^; u^ J°"™i \,^- ^" ... ^u 1 • ^ 11 J u i. 1-4- ^ct. 1, 1921), and he considers the more this method IS followed by no mortality, important factors which have in the There is an insignificant morbidity af- past, or may in the future, exercise a ter radiotherapy which is steadily grow- retarding or accelerating influence on ing less as the result of improved tech- the progress of treatment. Drugs, he nic. The field for surgery in the treat- says, find their most extensive applica- 4. £ ^u -J - ^ • ^ ^^ J n J tion in the field of medical treatment; ment of fibroids is fairly well defined, ^ut, to the thinking physician, treat- All tumors extending above the umbili- ment no longer consists merely in giv- cus and, likewise, all large pedunculat- ing drugs or applying other measures of ed, subserous or submucous fibroids relief. The essence of treatment con- should be operated on, for in these three ^'^^^ '"} recognizing the pathologic pro- , ,. ,, • 1-1 1 ^ J c^ss; in understanding its causes, the classes radiotherapy is likely to produce mechanism involved in its production a necrosis of the tumors. Cervical and in the deevlopment of its clinical fibroids are equally unsuited for radio- manifestations ; in knowing the charac- therapy, and should be removed surgi- ter, extent, and probable outcome of the cally. The same is true of suppurat- ^f "1*^"^ functional and morphologic ,. XI changes; in valueing correctly the sig- ing, necrotic or gangrenous tumors and nificance of clinical and laboratory find- those which are undergoing cystic or ings ; in ascertaining the indications for, calcareous degeneration. While the administration of drugs in disease and freouency of such secondary changes in i" knowing the mode of action of, and fibroids is not very great, they consti- f ^PJ'^y^^S the most effective measures Hif^ ov, ;.v,., t- ^ u- u X ^ ^01" Its prevention, abortion, ameliora- tute an important group which must be tion, or cure. As medicine becomes reserved for surgical intervention. As more rational, it becomes more effective, a rule, women under 40 should be op- and drugs play a relatively smaller but erated on rather than irradiated. The better defined role. The essentials of younger the patient, the more clearly is ^■^t^J-^^'^T^ ''''^- ^^J.^^t ^nd early ooeration advisablp diagnosis ; a true conception of the cause operation advisable. and nature of the derangement; famil- March, 1922. MISCELLANEOUS 161 iarity with the manner in which the de- rangement can be corrected, and the knowledge of, and ability to apply the most effective measure of relief. In the final analysis it is seen that the funda- mental factors responsible for the tardi- ness of medical progress have been : (1) the inadequacy of science during its early period of development, to cope with the complex problems of the hu- man organism and with the processes of life and of disease; (2) the incorrect approach to the subject, that is the em- ployment solely of speculation uncon- trolled by observation and experimenta- tion. The public and many physicians fail to recognize that progress comes through investigation, that practice is based on investigation and that med- ical investigation means better care of the sick, greater public health and hap- pier communities. Rowntree continues his address by taking up such topics as the evolution of science and the adoption in medicine of scientific methods; de- velopment of clinical medicine; the de- velopment of pharmacology ; the rela- tion of chemical constitution to phar- macologic action ; the discovery of micro-organisms and of their relation to disease; asceptic and antiseptic sur- gery; specific chemotherapy; nutrition, metabolism, and the functional concep- tion of disease. Lines of future devel- opment are indicated. A national in- stitute of pharmacology and experimen- tal therapeutics, Rowntree asserts would prove of inestimable value to American medicine. and the manometer connected with the needle begins to fluctuate as the tip reaches the adipose tissue surrounding the kidney. With the idea of inducing an emphysema in the perirenal adipose tissue, from 200 to 400 c.c. of carbon dioxid gas are injected, and a second roentgenogram is taken. The report, which is accompanied by six roentgeno- grams of normal kidneys and three of kidneys with calculi, indicates that, by this method, the authors have been able to show definitely the outline of the kidney, the ureter and the suprarenal gland. In the earlier experiments oxy- gen was used, but the investigators found that twenty-four hours were re- quired for absorption, and hence chang- ed to carbon dioxid. The little discom- fort that patients are reported to feel is said to disappear in less than half an hour when carbon dioxid is used. — Jour. A. M. A., Oct. 1, 1921. ♦ Carelli. H. H., and Sordelli, E.: Un nuevo procedimiento para explorar el rinon. Rev. de la Associacion Med. Argentina 34:424 (June) 1921. Injection of Gas to Outline the Kidney Among the newer methods of exam- ination brought to light during the last few years is the injection of air or gas into various body cavities, with subse- quent application of the roentgen ray, revealing the outlines of various organs and, in the case of the female genital tract, showing the patency of the fal- lopian tubes. Carelli and sordelli* have now applied a similar method to throw into relief the outline of the kid- ney. The technic involves a prelimi- nary roentgenogram to show the loca- tion and relations of the second lumbar transverse process. A narrow needle, 10 cm. long, is then introduced down to this bone. When the needle touches the bone, the tip is slanted away from it, Chaulmoogra Oil in Treatment of Tuber- culous Laryngitis This report by R. M. Lukens, Phila- delphia (Journal A. M. A., Jan. 28, 1922), gives the results of sixty cases of tuberculosous laryngitis treated over a period of eight months with chaul- moogra oil. The treatment was con- ducted more for the purpose of learning the effects on the pathologic lesions of the larynx and the symptoms than on the tubercle bacillus itself. Chaulmoo- gra oil gave promising results from the beginning in cases in which there were dysphagia and pain in the throat. In the majority of cases it exerted an an- algesic action on the larynx, which be- came more complete after repeated treatments. While improvement in the lesions is slower than was hoped for, yet cases treated with chaulmoogra oil have responded as rapidly as those treated with other drugs, and the treat- ment is much more easily borne. Pre- liminary cocainization has not been nec- essary, and there has been no pain or discomfort in the throat afterward, but rather a pleasing sensation of warmth in the throat and chest. In the cases in which intratracheal injections were made, sputum was rednered more fluid SOUTHERN MEDICINE AND SURGERY March, 1922. and was expelled with greater ease. Dryness of the throat, which frequently is present in tuberculous laryngitis, was improved but slightly in the major- ity of cases. At first the oil was applied by means of a cotton tipped applicator saturated with a 10 per cent, solution in liquid petrolatum directly to the laryn- geal surface. Later the strength was increased rapidly up to the pure drug. Chaulmoogra oil works best by intra- tracheal and intralaryngeal injection. One cubic centimeter of the oil, of the strength desired, usually 10 or 20 per cent, in liquid petrolatum or olive oil, is drawn up in a Luer syringe armed with a metal eustachian catheter. While the patient holds the tip of the tongue, wrapped in a paper napkin, between the index finger and the thumb of the right hand, the syringe tip is introduced, guided by the throat mirror, into the pharynx (not the larynx) above and be- hind the epiglottis, care being taken not to touch any portion of the mouth or throat. Two-thirds of the contents of the syringe is discharged, drop by drop, into the trachea while the patient breathes quietly. The remainder is then dropped on the cords while the pa- tient phonates. In this way, cough fol- lowing injection is very slight and often absent. When present, it occurs within five minutes after the injection and lasts for a minute or two. said. Carcinoma is in the beginning a local disease. It is definitely known that irritation of tissues favors its pro- duction. There has also been accumu- lated evidence as to the earliest signs by which malignant growths manifest themselves. It is well to give the pub- lic such facts as these, to advise early consultation with the family physician, and to point out that we have thus far but one sure method of treatment, and that is complete removal of the danger- ous growth. The condition itself is suf- ficiently serious and needs no elabora- tion as to its terrifying aspects. Give the public all the facts — but facts only. —Jour. A. M. A., Oct. 29, 1921. Publications Received Cancer Phobia An inevitable accompaniment of di- recting special attention to any disease is to arouse in a certain number of per- sons phobias almost as terrifying as the diseases feared. To warn the public that "moles, excrescences, fistulas and warts" "are the first signs of cancer" is to erect a specter capable of shatter- ing even a normal mentality. To say that "sympftoms of indigestion" are "signs of cancer" is so small a part of the whole truth that it is better left un- DISEASES OF THE EYE. A Hand- book of Ophthalmic Practice for Students and Practitioners. By Geo. E. deSchweinitz, M.D., LL.D. Pro- fessor of Oohthalmology in the Uni- versity of Pennsylvania. Ninth Edi- tion, Reset. Octavo of 832 pages with 415 text-illustrations and 7 colored olates. Philadelphia and London: W. B. Saunders Company, 1921. Cloth, $10.00 net. In the Ninth Edition of this textbook, the revision includes reference to im- portant ophthalmic observations, thera- peutic measures and surgical procedures which have been made, recommended and devised during the last four years. Reference to the following subjects aooears for the first time: Jennings' Self-Rpcording Test for Color Blindness and Nagel's Card Test; Oothalmo scopy with Red-Free Lisrht; Measure- ment of Accommodation by Skiascopy: Electric Desiccation in the Treatment of Lid-Carcinomas and Eoibulbar Growths: Unusual Forms of Conjunc- tivitis: Poisonous Gas Conjunctivitis; Striate Clearing of Corneal Opacities; Trypanosome Keratitis ; Suoerficial Lin- ear Keratitis: Keratitis Pustuliformis Profunda; Primary, Progressive Calca- reous Degeneration of the Cornea; An- terior Leriticonus; Cysticercus of the March, 1922. MISCELLANEOUS 163 Vitreous (previously only mentioned) ; ABDOMINAL PAIN, by Prof. Dr. Nor- Localization and Organization of the bert Ortner, Chief of the Second Med- Cortical Centers of Vision, according to ical Clinic at the University of Vi- Holmes and Lister; Contusion and Con- enna. Authorized translation by cussion of the Eyeball in Warfare ; Ep- William A. Brams, M.D., and Dr. Al- idermic Grafts for the Correction of fred P. Luger. 362 pages. Rebman Ectropion (Epithelial Overlay) ; Free Co., Herald Square Bldg., New York Dermic (Whole-Skin) Grafts for the City. Correction of Ectropion (previously The author says: "We include in only briefly recorded) ; Epithelial Out- this large chapter all those diseases in lay for the Correction of Ectropion which the particular complaint of the (Gillies' Operation) ; Esser's Epithelial patient is pain in the abdomen. Post- Inlay; Maxwell's Operation for Con- traumatic affections, such as those fol- tracted Socket; Conjunctivoplasty ; lowing an accidental rupture of the Modified Brossage, Simple Excision of spleen, etc., are not considered in this the Retrotarsal Folds, and Combined connection. Fortunately, we are seldom Excision of the Retrotarsal Folds (Heis- called upon to make a diagnosis on the rath's Operation) in the Treatment of consideration of the pain alone. There Trachoma; Trephining the Sclera for soon develop other and objective find- Detachment of the Retina; Sclerotomy jngs which aid us; but the pain often combined with Electrolytic Punctures points out the direction we must follow for Detachment of the Retina (Ver- in the objective examination in order to hoeflf's Operation) ; Resection of the arrive at the proper diagnosis. It is Sclera for Detachment of the Retina one of the early symptoms and serves (Mueller's Method) ; Cartilage Implan- as a guide through the maze of possi- tation After Enucleation of the Eye- bilities, and, therefore, it seems justi- ball : Mosher's Operation for Dacryo- fiable to me to consider the pain as the cystitis. starting point in the differential diag- In certain portions of the book the nosis." revision has included a rearrangement, with additions, of the subject-matter, for example, in the paragraphs devoted PSYCHOANALYSIS : ITS THEORIES to Visual Field Examination, Glaucoma, AND PRACTICAL APPLICATION. Sympathetic Ophthalmia, and Blepharo- By a. A. Brill, Ph.D., M.D., Lecturer plasty. More frequently than in previ- on Psychoanalysis and Abnormal ous editions, foot-note references to im- Pathologv, New York University, portant publications have been inserted. Third Edition, thoroughly revised. A number of new illustrations have Octavo of 468 pages. Philadelphia been added. and London : W. B. Saunders Com- pany, 1922. Cloth, $5.00 net. THERAPEUTICS. PREVENTIVE As a result of its successful awplica- MEDICINE, — Practical Medicine Se- tion to a large number of psychoneu- ries, 1921. By Bernard Fantus, roses precipitated by the war, psycho- M.S., M.D., Associate Professor of analysis has gained many new adher- Theraneutics, Rush Medical College, ents among physicians who were hith- and William A. Evans, M.S., M.D., erto unacquainted with it. LL.D., D.P.H., Professor of Sanitary it has made progress both as a thera- Science, Northwestern University neutic agent and as an exoounder and Medical School. The Year Book Pub- interoreter of subjects and phenomena hshers, 304 South Dearborn St., Chi- ^hich are not strictly medical. As cago. Price for this volume, $1.75. pleasing as these results are there have Price for the Series of eight volumes, been, nevertheless many criticisms hurl- 12.00. Q^ at nsychoanalvsis, by those even seri- The publishers of the Year Book ously interested in the subject because strive to adapt this series, and this fh^T- }-,ave not really understood. volume primarily to the general prac- The author has, to a remarkable de- titioner, yet the arrangement in vol- i -a -, .-l, ^ i, " j umes enables those interested only in ^r^^' ^^^^^^^d ^^^'^ ?^«°t P^^«^.^ ^"f special subjects to obtain at the mini- ^^^^ work will do much to reconcile the mum cost the subjects they wish. differences of opinions. SOUTHERN MEDICINE AND SURGERY March, 1922. Table of Contents for March, 1922 Registration at Norfolk Meeting, Febru- Editorial ary, 1922 109 » ^ , t^ . ^. ■ i,T r, TH, ^ J X XT . „ ,,' . , Indulgence Destroys Stamina 144 Members Elected at Norfolk Meeting of Unprejudiced Jurors __ _ _ 145 the Tri-State February 22-23, 1922 110 North Carolina Medical'sodety""".:" 145 Roster of Officers of the Tri-State Med- _ . ^ c- ..^ ical Association from Organization in Department Editors 1898 to Date 111 Gynecology and Obstetrics, Robert E. Sei- S. S. Gale, M.D, President 113 ,, ^els, M.D . . 146 ^ . , , , , Urology, A. J. Crowell, M.D 148 Transactions of the Twenty-fourth Annual Cental and Nervous, Jas. K. Hall, M.D._- 149 Session of the Tn-State Medical Associ- gy^^ ^ar. Nose, and Throat, J. P. Mathe- ation of the Carolinas and Virginia, g^^ jyj p 249 Norfolk, Va. 114 OrthoWedicsrAlonzo' Myers," m'd..'IIIII 151 Transactions of the Meeting of the Ex- Neurology, R. F. Leinbach, M.D 152 Presidents Society of the Tri-State Med- Roengenology, Robt. H. Lafferty, M.D.__ 153 ical Association, February 22, 1922 120 Hospitals and Sanatorium, John Q. Myers, Presidents Annual Address 120 M.D. 154 Clinical Observations and Research Work, News Items by John B. Deaver, M.D ^^122 Meetings and Societies 154 Rambling Remarks in Re Appendicitis, by" Personal Mention 155 Stuart McGuire, M.D. 124 Proceedings Norfolk County Medical So- Auto-Transfusion, by Chas. S. White, M.D. 126 ciety 156 Headache with Especial Reference to Specialism vs. Country Doctor 159 Those Due to Sinus Infection, by H. C. M:o/..»iior.<»«..o QVi ■ 1 M r» 19Q miscellaneous „ ' ' ' ~~ "V Z,r "," T When to Operate and When to Use Radium Cancer Propaganda, John Wesley Long, ^^ Fibroids of the Uterus 160 M.D. 131 Role and Development of Drug Therapy__ 160 Brain Injuries — Remarks Regarding the ... , „ ^ ,. ^ t,.j Pathology. Diagnosis and Treatment, by Injection of Gas to Outline the Kidney__.. 161 William Sharpe, M.D. 136 Chaulmoogra Oil in Treatment of Tuber- Removal of Ureteral Stone by Cystocopic culous Laryngitis 161 Manipulation, by Albert D. JParrott, M.D. 142 Cancer Phobia 162 Carbon Monoxide Poisoning 143 Publications Received 162 TRANSACTIONS OF THE TWENTY- INFANT FEEDING. By Clifford G. SEVENTH ANNUAL MEETING Grulee, M.D., LL.D., Associate Pro- OF THE AMERICAN LARYNGO- fessor and Acting Head, Denartment LOGICAL, RHINOLOGICAL AND of Pediatrics at Rush Medical Col- OTOLOGICAL SOCIETY, INC., held lege. Fourth Edition. Thoroughly in Atlantic City, N, J., June 3 and 4, Revised. Octavo of 397 pages, illus- 1921. New York: Published by the trated. Philadelphia and London: Society. $4.50 net. W. B. Saunders Co., 1922. Cloth, TRANSACTIONS OF THE COLLEGE The author claims as his purpose in OF PHYSICIANS OF PHILADEL- nreparing this work to do two things: PHIA. Third Series. Vol. 42. Phil- pirst, to bring our knowledge of the adelphia. Printed for the College, scientific processes which underlie in- 1920. Edited by Walter G. Elmer, f^^^ f^.^i^^ „p ^^ ^he present, and. This' volume of Transactions contains second, to put forth the practical appli- the papers read before the College from cation of these principles in such a way January, 1920, to December, 1920, in- that they can be grasped by the prac- clusive. ticing physician. The volume itself is The Committee of Publication thinks p^oof ^f the measure of success Dr. Gru- it proper to say that the College holds , ^-^.-j-u-a^^t^ t.- itself in no way responsible for the ^^^ attained in his effort. Every physi- statements, reasonings, or opinions set ^^^n who occasionally or constantly sees forth in the various papers published in babies will find it a book well worth its Transactions. having and studying. Southern Medicine and Surgery Vol. LXXXIV CHARLOTTE, N. C, APRIL, 1922 No. 4 EMPHASLS ON THE STUDY OF THE ^^Ti'^^"' ^'^^''^''' J^^ 1""^'"^ tabulated signs give evidence which will CLINICAL SIDE OF TUBER- bear consideration: CIJLOUS JOINTS* 1. Mon-articular. By Alonzo Myers, M.D.. Charlotte, N. c. (Second joint — less severe.) Formerly a group of clinical signs ^' Remissions-usual ; development— and symptoms were the only means by l^^j , which the diagnosis of the tubercular Residual symptoms-persistent, character of joint disease was made. )f/ deformity, This information did not furnish the )^( ,1^?' ^. , .,. fine distinctions as to the character of ^( ^^'^}^. disability, an arthritis. o .. • ^"^^ swelling, Later the clinical evidence determin- ^/ Pain-not prominent, ed the presence of disease and the gen- ^^ S^^^"^"^ (synovia ) . eral course of a disease was suggestive ^^«"? ^^!^^ ^^^^^^^ membrane, in distinguishing between tubercular _ _ nuid. and acute infectious processes. ^- Temperature-0. . , ^. , Today the problem is a different one. ^^^ ^^^^^ secondary infection). With the X-ray, laboratory tests, and 1- I" ^ very great majority the dis- surgical exploration of joints, the true ease is mon-articular in manifestation, pathology is most often determined, The second joint, when it exists, follows when formerly it was only suspected, tardily on the first, is much less severe, since distinctions are so fine, that for ^nd its course less destructive. This is positive proof, it is necessary to use all ^" ^'^ probability due to the fact that laboratory tests at hand to determine ^^e second, or the other joints, are of the character of anv suspected lesion, toxic rather than of bacterial invasion. In a given case, the first step to de- described by Poncet as tubercular rheu- termine the presence of a disease is rnatism. easy ; but the second step, to determine In the non-tubercular forms, the rule whether the disease is of a tubercular is not only to have a multiple joint in- or non-tubercular origin, is the one of vasion, but the various joints are af- importance, for on it the principles of fected with various degrees of severity, treatment and the question of progno- destruction and frequency, and with sis will depend. chronological difference in their appear- On account of the rather definite an- ance. Also the joint which proves to swers given by laboratory tests. X-rays, be the most serious is frequently not etc., it is extremely difficult to give the the first invaded. clinical side its importance after these 2. Development and Remissions. The other sources have biased our opinion, development is slow, extending over a and it is on account of this importance period of months, and sometimes years, that leads to this plea for emphasis on and, in the early periods, the disability the study of the clinical side, which ap- is, in a very large number of cases, to pears to be in danger of neglect. a surprising degree, slight. This slow This paper aims to suggest the gen- development is attended with remis- eral clinical characteristic elements in sions, which are almost invariably pres- ent, and form a symptom which must *Read before the Norfolk meeting of the be regarded as most important. A fea- Tri-State Medical Association, February 22-23, ture of these remissions, also of mark- 1922. ed value, is that the disability never 166 SOUTHERN MEDICINE AND SURGERY April. 1922 entirely disappears, but shows a residue ance cannot be put on these signs alone, in one or more of four features. These but all tests which may be given by are (a) deformity, (b) limp, (c) slight laboratory methods are necessary to de- disability, (d) swelling. The (a) de- termine the character of the condition, f ormity may not be noticed at all times ; and since we do use these other guides, frequently present in the morning on it is of value to have a definite routine rising, but disappearing after use ; or a of examination in any case suspected of very slight residual deformity is left, tubercular joint disease. Therefore a which is later found to have existed schedule of examination is convenient, only after careful questioning. The (b) an example of which is here given : limp and (e) slight disability are no- r c^, j , ticed only on active or forced exertion, „. , Slow development . r,n . . . J. • i J. 1 History • Remissions, Limp Defomity. not sufficient to restrict to usual rou- ( Residual. Pain, slight, tine. The (d) swelling can be detected _, . ^ , , ^, only in the most superficially placed J°'°^ Involved, Knee, joints and in thin subjects. It is, as a ( Capsular swelling, rule, a swelling from a residual thicken- l:?^^^ ■ ^^^^'*?"' ing of capsule rather than fluid, and ^'^"* / plin^H ht does not change except with the exacer- bations Duration One year. 3. Pain In the attacks pain is pres- ^,t^p',Tamre 98°f.o 99.6. ent, usually most noticeable as sensi- tiveness and disappears with the acute- Urine \ ?°^°J ^^^^- ^P;,^""- ^!^ ^^^- ^^^'j ness of the attack. In the disability / High Ac. 1.018 '0 0 Neg. Nasal Cavity, Negative. which is found as a residuum in the Blood ^ Haem, 80%. remissions pain is not a usual symp- Exam- Whites, 5,900. ^^^ ^ ^ ^ ination (. Keds, 5,864,000. The amount which is left usually de- ( Von Pirquet, Positive, pends upon the amount of involvement Reaction Tuberculin, Tempt. x3 c.lmg. of the real articular surfaces of the ^^^^^ / T^T"^^""":. Negative. ... Luetin. Neii-ser, Negative, joint. 4. Swelling. Fluid in the tubercular Naso- ^ 3-°"^/^'jJ^'^^^.^\''^- joints is not usual, unless it be pus, and Pharynx ( ycT^\{ rf^fifJ^xi this naturallv as a late symptom, and when destruction has occurred and p^^t^'O" ( Acidity, Negative, when diagnosis is no longer in doubt, ^"^f^f ' ^ro's^Nrg'^'ti^^"""'- The swelling (in superficial joints) has 'pj.act Stools! Negative, much the feel of fluid, but is due to the thick, vascular synovial membrane, gives an elastic feel closely resembling cufarif ^"'^' ^""^ ^^""'^^ ^'^^ *^^ ^^^' DUODENAL ULCER AND 5. Temperature. Temperature is not CHOLECYSTITIS* to be expected in the slowly developing By Warren T. Vaughan, M.D., Richmond, Va. and quiet joints. It is on the clinical side that empha- The differentiation between chronic sis is made in this communication, as cholecystitis and duodenal ulcer is still being one which gives us not only a sufficiently difficult to justify further valuable aid in diagnosis, but the one discussion, particularly in an attempt to always at hand, and many times the better explain the frequent close clinical only one. Many a case will be seen by the general practitioner, away from the *Fi-om the Medical Service of St. Eliza- large centers, where the confirmatory heth's Hospital. Read before the Norfolk meet- tests cannot be made. But in our best mg of the Tri-State Medical Association, Feh- equipped n'ethods of examination reli- ruary 22-23, 1922. April, 1922. SOUTHERN MEDICINE AND SURGERY 167 similarity between the two diseases. against the palpating fingers will elicit Classical duodenal ulcer is character- the same jerky painful response. This ized by pain or distress, coming on occurs in many cases in which the gall- quite regularly from one to three or bladder is not under suspicion, more hours after meals, and relieved by Spasticity of the abdominal muscles the taking of food or alkali. In cases in the right upper quadrant is certainly complicate:! by pyloric obstruction, the more frequently found in cholecystitis pain may persist well into the night, than in ulcer. So likewise is cutaneous This symptom complex is rarely found hyperasthesia to painful stimulation, as in pure cholecystitis, where the distress by pin-scratching or pinching. These often occurs earlier after meals, but two phenomena when present are of with considerably less regularity, and is undoubted diagnostic value, less constantly relieved by food. There can be no doubt that in the In both diseases, the symptoms may vast majority of cases the anamnesis be intermittent. In both, nausea may is of greater importance than the physi- or may not be present. Vomiting may cal findings in the differentiation of or may not be present. Constipation is these conditions. characteristic of both conditions. In The findings on gastric analysis are either there may be no complaint of variable in both ulcer and cholecystitis. gas, or in either it may be a trouble- In either there may be present a sub- some or even the chief symptom. It acidity, normal findings, or a hyper- may only accompany the pain and dis- acidity. Several of the older text books tress, or it may occur independently, have described hyperchlorhydria as particularly in gall-bladder disease, characteristic of cholecystitis. Although Again, the patient may complain of there is considerable variation, our ex- practically continuous abdominal disten- perience has been that a subacidity is tion and flatulence in either condition, more frequently found. Several of the The gas may be present in the stomach more recent writings agree on this point, and accompanied by belching, or it may The findings on gastric analysis are of occur chiefly in the colon and be passed sufficient confirmatory value to war- by rectum. rant the application of this method of Short cuts to the diagnosis of cho- examination in the differential diagno- lecystitis by physical examination have sis. In cholecystitis, subacidity or an- in the main been of no great assistance, acidity is the more frequent finding— The presence or absence of tender pres- while in duodenal ulcer the findings are sure points has been discussed repeat- more often either normal or of an in- edly. Certain French authors have de- creased acidity. scribed an absence or diminution of the Fortunately, the roentgen-ray gives normal vesicular respiratory murmur valuable information in these condi- in the right lower axilla in cases of tions. The absence of a filling defect in cholecystitis. We have found normal the duodenal shadow usually eliminates breath sounds, on the contrary, to re- the possibility of duodenal ulcer. Even main present in this area in some cases here, however, the facilities for differ- of both acute and chronic cholecystitis, entiation are not absolute, as in two with diagnosis corroborated at opera- cases operated on at St. Elizabeth's tion. during the last year. In both there The presence of a jerking pain on was no defect, but in the first there deep inspiration when the examiner's was a superficial bleeding erosion, and hand is hooked under the rib margin in the second an old ulcer with consid- has recently been described as charac- erable evident repair. In both cases, the teristic of gall-bladder involvement. It operation has resulted in complete re- has been my experience, and without covery from symptoms, doubt the experience of many, that The presence of a constant filling de- when a liver is barely palpable on deep feet may mean ulcer. It may mean inspiration, the thrust of that organ pressure from some tumor or some 168 SOUTHERN MEDICINE AND SURGERY April, 1922. other organ, such as the gall-bladder. It may be due to adhesions between the gall-bladder and the duodenum, or ad- hesions between the duodenum and some other organ. It is true that as a rule a competent roentgenologist can differentiate be- tween filling defects due to duodenal ulcer and those due to adhesions to the duodenum, particularly from an in- flamed gall-bladder. This cannot al- ways be done, and unfortunately, some of the indirect roentgen signs of ulcer, such as hyperperistalsis, hypermotility, and where there is some pyloric ob- struction, delayed emptying, are found also in some cases of cholecystitis with adhesions. The recognition of cholecystitis by roentgen examination is usually accom- plished only from indirect evidence. The presence of a gall-bladder shadow does not always indicate that the organ is diseased. Spasticity of the pyloric end of the stomach, with a resultant "taper- ing pylorus," or "spiggot-shaped pylor- us" is, when present, suggestive of gall- bladder involvement. Variations in the motility or in the emptying time of the stomach are of some assistance in es- tablishing a diagnosis when disease in the duodenum and elsewhere has been carefully eliminated. The results of transduodenal lavage, as described by Lyon, may be of some value in differentiating between ulcer and cholecystitis, but at the present time this work is still in an experimen- tal phase, and in all probability, both the theoretical considerations and the interpretation of results will be more or less modified before the method be- comes generally accepted. In the present discussion we are in- terested particularly in attempting to explain, if possible, the inter-relation- ship between the symptoms of ulcer and of cholecystitis. In the series of cases which he have studied we have found it relatively easy to differentiate pure, uncomplicated cholecystitis from simple duodenal ulcer. The difficulty in differ- entiation arises when both the duode- num and gall-bladder become simul- taneously involved. The various combinations found at operation besides the two pure lesions are: (1) involvement of the mucous membrane of both organs; (2) involve- ment of the serous layers oi both or- gans, usually with adhesions between the two and with little or no recogniz- able disease in the mucous membranes ; (3) inflammation of both the external and internal coats of either organ alone ; (4) ulcer or cholecystitis with evidences of serous inflammation of the other organ, as indicated by the presence of adhesions. Late pain and gnawing or distress, relieved by food or soda, is found char- acteristically in pure duodenal ulcer. In our experience it is also present in ulcer complicated by periduodenal adhesions and by adhesions between the duodenum and the gall-bladder. It may indeed be present in duodenal ulcer accompanied by an actual cholecystitis. We have rarely found it to be present in uncom- plicated cholecystitis, but it does occa- sionally occur in cases of the latter dis- ease when complicated by adhesions to the duodenal serose. In other words, the typical duodenal ulcer symptoms usually occur in ulcer, or ulcer with ad- hesions, or in cholecystitis with adhe- sions to the duodenum. However, in cholecystitis with duode- nal adhesions, there is usually some ad- ditional feature in the history not char- acteristic of ulcer, and serving to cast suspicion on the gall-bladder. Among the chief of these additional symptoms I have found to be the radiation of pain toward the right scapula, paroxysmal type of pain, a history of jaundice, and for some reason, a history of inability to eat a few certain articles of food. This last symptom is exceptional even in our gall-bladder histories, but when present it usually points to involvement of that organ. In the roentgen examination we are particularly interested in the type of filling defect associated with adhesions to the gall-bladder, with or without ul- ceration of the duodenal mucosa. It is at times absolutely impossible to differ- entiate by the roentgen-ray alone, pure duodenal ulcer from cholecystitis, with- April, 1922. SOUTHERN MEDICINE AND SURGERY 169 out ulcer, but with adhesions to the two cases symptoms recurred, and at a duodenum. It was formerly taught that secondary operation the duodenal mu- tenderness on pressure directly over the cosa was found to be normal, while the filling defect indicated ulcer. We have symptoms appeared to be due entirely found it in cholecystitis with duodenal to dense adhesions between the outer adhesions, without ulcer. coat of the duodenum and the gall-blad- Motility of the duodenal cap on pres- der. We have thus been able to study sure occasionally assists in the roent- the relationship between symptoms due gen differentiation. This again is only to ulcer, and those due to periduodenal successful in the hands of the expert, and pericholecystic adhesions, and even then, does not always enable Patient J. B. was first admitted to a satisfactory differentiation. St. Elizabeth's October 3, 1918. The Various observers have suggested gastrointestinal history extended over that the similarity in the symptoma- a period of eight years. He complained tology of duodenal ulcer and cholecys- chiefly of pain in the epigastrium com- titis is due primarily to the closely re- ing on from one to three hours after lated embryologic development between meals, which was relieved by food or the two organs. It will be remembered soda. He did not vomit. The attacks that the biliary tract develops as an would last as a rule for about four evagination from the duodenum, and weeks, with intervening periods of free- that the nerve supplies of the two or- dom from complaint of four or five gans are thereby very intimately re- months. He had had an appendectomy lated. While this is a fact, I do not in 1916. The appendix was found to be think that it satisfactorily explains the not diseased. findings. As a matter of fact, it is ^t operation there were found a usually when there is mvolvement of duodenal ulcer, pericholecystic adhe- both organs, either externally or inter- ^^^^^^ Lane band, pericecal adhesions, nally, that the picture becomes dis- ^^^ diverticulum at the old site of the tinctly obscured, and I am led to con- appendix. Operation consisted in ex- clude from our findmgs that the pres- ^.jgj^^ ^f ulcer, Horsley pyloroplasty, ence of adhesions is of considerable sig- reparation of adhesions, and infolding of nificance in relation to the symptoma- ^^^e diverticulum. tology. As a rule, the importance of ^-.i iu i j. ^-i, +• i- ^^ ,, ^•^. , , T U4^i J Eleven months later the patient re- adhesions has been lightly passed over, ^ , tt u j j ,Zu -e^^ v,iv.« , . , , '^ . f • , , turned. He had done very well lor nine or even denied by many internists and ^ ^ ^^.^^ ^^ .^^^ ^^^^^ surgeons. In certain parts of the abdo- ^^^^^^ .^ ^ ^luring the succeed- men It is true that adhesions may give j ^^^ ^ ^^^ indigestion rise to few or no symptoms. Particu- J^^.^^^ accompanied by gas and dis- larly is this true where considerable ^^^^^^,^ ^^^^jl ^^^.^^ ^^^^^ j^^^rs freedom of moyenient IS allowed by long ^^^^^. ^^^j^ ^^^ ^.^^ epigastric pain, mesenteric attachments. But m the j^^ ^j^^ ^^.^^^ ^^ p^i„ i„ the right pylorus and duodenum where the or- ^^j^ ^^ ^^^ abdomen, coming on with gans are normally quite firmly fixed, ^^^^^. ^^ ^-^^^^ ^^^ requiring additional impairment of motility pro- ^^^ ^inft for relief. Again, there was duces very definite symptoms ^j ^^^ ^^ but no vomiting. We have been particularly fortunate . ,, , i- ^.i, • r.- J. -^ J. 1 J £ At the second operation there were in having opportunity to study a few ^^ ^' ,, . ^ , ,, n ui ^ cases in whom duodenal ulcer was found dense adhesions around the gaU-blad- to be present at the first operation, to- der and between the gall-bladder and gether with adhesions to the gall-blad- duodenum. These were separated and der, but in whom the gall-bladder other- the pylorus and duodenum were thor- • J i. u 1 mu 1 ouehlv inspected and found to be m ex- wise appeared to be normal. The ulcer ""s^^J^ '"''^:,\ „, , ^ .o+^^f^»v,,r ,,ra = J 1 ,14. cellent condition. Cholecystectomy was was removed, and a pyloroplasty was L-eueni. ^""«- j' , . , performed, while the adhesions to the performed, and a chronic catarrhal gall-bladder were broken up. In one or cholecystitis was found to be present. 170 SOUTHERN MEDICINE AND SURGERY April, 1922. This case exemplifies the fact that due to adhesions and they persisted, to- cholecystitis with adhesions to the gether with the adhesions, until, by duodenum may be responsible for per- gastro-enterostomy, the pylorus and sistence of typical ulcer pains after re- duodenum were relatively immobilized, moval of the ulcer. Rarely, bands formed in the region Patient L. W. P., admitted in April, of the gall-bladder and duodenum dur- 1920, gave a history of six months' ing embryonic development may cause duration, with paroxysmal attacks of symptoms and produce physical changes pain just below the xiphoid, coming which cannot be clinically differentiated about once a week without definite re- from ulcer or cholecystitis. When in- lationship to meals, made worse by food volving the gall-bladder in adhesions, or soda, or by jolting as in automobile such a condition is sometimes termed riding. Pain was the dominant symp- "pseudo cholecystits." These bands are tom. There was some nausea and vom- analagous to the familiar Lane band iting. At operation a duodenal ulcer found in the lower abdomen, and were was found which evidently had perfor- first fully described by Morris, who ated slowly and was occluded by ad- coined a happy phrase in designating hesions between the gall-bladder and them "cobwebs in the attic of the ab- duodenum. The ulcer was excised, domen." Horsley pyloroplasty was performed. Occasionally such extrinsic adhesive and the adhesions were separated. With bands may form as a result of inflam- the exception of the adhesions, the gall- mation, without involvement of the mu- bladder appeared normal. cous membrane of either the duodenum Three months later the identical or the gall-bladder. Such rare pathol- symptoms returned, but with slightly ogic conditions are from their very na- lessened severity. At operation in No- ture practically never correctly diag- vember, 1920, the pylorus was found in nosed, except at operation, excellent condition, and the duodenum For the purpose of facilitating this appeared normal. There were dense analysis I have chosen cases with little adhesions about the gall-bladder and or no additional pathology. In clinical between the gall-bladder and the stom- work, however, the picture is further ach and duodenum. The gall-bladder obscured by disease elsewhere, particu- was removed. On examination after re- larly in the appendix. The following moval, this organ showed little evidence case exemplifies the confusion that may of disease. The contents appeared nor- thus arise : mal, and the walls were thick and Patient J. H. S., age 37, entered St. slightly congested. Elizabeth's December 7, 1921, complain- After an interval of six months the ing of eructations of gas one hour after symptoms again returned, and were meals, and often before breakfast, and again of the same character except that accompanied by a burning pain and sen- they were somewhat less frequent and, sation of pressure in the right hypoch- if anything, more severe. A third oper- ondrium. He had had typhoid at 18 ation was performed in August, 1921. and the symptoms dated from around Peripyloric and periduodenal adhesions that time. During the last eight months were again found. There was no recur- the symptoms had become distinctly rence of ulcer. Posterior gastro-enter- more severe, with definite pain in the ostomy was performed, and the pylorus right hypochondrium and back, coming was occluded. on one hour after meals and relieved by It is but five months since the last soda or gastric lavage, and rather less operation, but the patient has remained constantly by food. The patient believ- entirely symptom-free. Appetite is ex- ed he had been jaundiced twice within cellent. He has gained ten pounds in the last eight years, and he described weight. clay-colored stools. Physical examina- In this second case the symptoms tion showed nothing with respect to the throughout appear to have been mainly enterologic condition other than some April, 1922. ORIGINAL COMMUNICATIONS 171 slight increased muscle tonus in the right upper quadrant. There was no tenderness and no cutaneous hyperaes- thesia. A diagnosis of cholecystitis with adhesions to the duodenum was made. Subsequent X-ray examination showed a pointed or tapering pylorus, and a filling defect or sacculation in the second portion of the duodenum. At operation the stomach, duodenum and gall-bladder were found to be nor- mal. There were many adhesions from the omentum and mesocolon to the liver. The omental fat in this region was de- cidedly infiltrated, and brownish pig- mentation at one point suggested the presence of a small abscess which had gradually been absorbed. The appen- dix was chronically inflamed, pointed upward and outward, and was densely adherent. The inflammatory mass in the upper abdomen may have been caus- ed by the appendiceal inflammation. Just a word regarding one important practical application of our studies. I have followed up all cases of duodenal ulcer operated on at St. Elizabeth's in which pyloroplasty has been performed. In other words, I have studied those cases in which cure of the ulcer was accomplished with a minimum of struc- tural and functional alteration. All of those cases in which simple duodenal ulcer was found have remained entirely symptom-free. In four cases, although there were adhesions to the gall-bladder, that or- gan appeared otherwise so healthy that the adhesions were merely separated and the gall-bladder was neither drained nor removed. Three are unimproved, while the fourth, although distinctly im- proved, is not well. On the contrary, all cases of ulcer with gall-bladder adhesions or cholecys- titis in which the bladder was also oper- ated on, have remained well. In one the gall-bladder was drained. In the remainder it was removed. Here again I have used only those cases not obscured by extensive addi- tional pathology or by extensive adhe- sions elsewhere in the upper abdomen. The importance of cholecysto-duode- nal adhesions is again emphasized by this series. If they do not cause symp- toms per se, they predispose to gall- bladder infection by producing stasis in that organ or even by affording in the presence of an ulcer a direct path of infection through from the duodenum. It has not been my intention in the foregoing discussion to intimate that we have evolved a method of differen- tiating ulcer and cholecystitis. We have scarcely even simplified it. Further- more, it should be stated that we have seen cases of the various types of le- sions discussed which do not conform to the preceding symptomatic classifica- tion. My chief aim has been, first, to call attention to the importance of ad- hesions in these conditions, and their influence on the clinical picture — and second, by analysis of operated cases, to clarify if possible the inter-relationship between the three pathologic conditions. Time does not permit any detailed case reports further than brief reference to two or three illustrative cases. Discussion by Dr. J. Shelton Horsley, Richmond, Va.: This paper of Dr. Vaughan's is very interesting to me, as Dr. Vaughan is my partner and observes these cases from the standpoint of an internist. He and I are co-operating in an effort to clear up some features of these cases that are quite puzzling. Unfortunately, duodenal ulcer has been treated empirically and gastro-en- terostomy has been done almost as a routine, because in many cases it re- lieves symptoms. If these patients are followed up, however, many of them will be found a year or more after the operation with distinct stomach symp- toms, which are probably due to a je- junal ulcer or to irritation of the jeju- num by the acid gastric contents. Much has been said in recent years of focal infection. If it is necessary to remove a small apical abscess at the root of a tooth for focal infection, it seems much more important to remove an ulcer of the stomach or duodenum which is a constant source of toxic ma- terial and which is subject to almost continuous massage by the peristaltic waves. An ulcer in the first inch of 172 SOUTHERN MEDICINE AND SURGERY April, 1922. the duodenum is best treated by a py- loroplasty with excision of the ulcer. The pyloroplasty weakens the sphinc- teric action of the pyloric portion of the stomach, and tends to induce rest, just as the sphincter ani is temporarily paralyzed by incision when an ulcer in the rectum is excised or treated. By so reducing the sphincteric action the tissues on the oral side of the sphincter can expel their contents more readily and with less effort. There are certain ulcers in the duode- num accompanied by extensive leuko- cytic infiltration in which pyloroplasty cannot be done. This type of ulcer usually results in a stenosis and gastro- enterostomy is more satisfactory. In ulcers accompanied by extensive scar tissue, where the duodenum and pylorus are so affected as to have their normal function practically abolished, gastro- enterostomy is fairly satisfactory. Gas- troenterostomy is, as Dr. Finney says, a confession of failure, and should be done only when the pathology is so ex- tensive as to make it plain that the physiology cannot be restored. It should be used just as an amputation of a leg is advised, when the leg is so crip- pled that its function without amputa- tion would be almost abolished, so when the pyloric end of the stomach and the duodenum is so shot to pieces with pa- thology that it cannot be restored even to approximate normal, gastroenteros- tomy is the proper operation. In other instances, when the ulcer can be excised or when there are only a few adhesions or a narrow thin steno- sis, pyloroplasty is, in my judgment, by far the best procedure. SARCOMA OF THE LONG BONES* Jas. W. Gibbon, M.D., Charlotte, N. C. Malignant tumors of bone constitute 3ne of the most important fields of a surgeon's work. "Their very frequent occurrence, local destructive tendencies *Read before the Tri-State Medical Associa- tion of the Carolinas and Virginia, Norfolk, Va., February 22-23, 1922. resulting in loss of limbs, rapid exten- sion with loss of hfe, and the difficul- ties in establishing the prognosis ren- der them a complex surgical problem" (Ewing). Within recent years our knowledge regarding these lesions has very greatly increased, but even yet ac- curate correlation of clinical features, X-ray appearances, pathology and prognosis is lacking, and further inves- tigation is needed. Pathology — There is no uniform class- ification of the primary sarcomatous tu- mors of bone and bone marrow, but that of Ewing seems to be most generally accepted, and perhaps the most simple and reasonable. These tumors are di- vided into four great groups: 1. Os- teogenic Sarcoma; 2. Giant Cell Sarco- ma, 3. Myeloma, and 4. Endothelioma (Ewing). Of these the most important, by far the most frequent, and the ones principally to be considered herein are the osteogenic sarcoma and the giant cell or epulis type of sarcoma. The myeloma and endothelioma are very rare tumors, and may be dispensed with briefly. Osteogenic sarcoma, the largest and most common of these groups, spring originally from the fibroblasts, or ordi- nary connective tissue cells, which are normally the progenitor of bone form- ing tissues of the body. Whatever the anatomical variety, wherever the loca- tion, periosteal or central, osteogenic sarcomata are produced from these cells always. It is worthy of note that these fibroblasts, whose chief function then is the production of bone, are capable of very wide degrees of differentiation, and often give rise to tumors which retain more or less the function of bone production. When this differentiation is not marked, or absent, and these cells seem to retain none of their nor- mal function but are devoted solely to rapid and exaggerated reproduction, the. tumor produced is a soft and succulent mass of pleomorphic cells of irregular form, and of high malignancy. The more complete differentiation of the spindle cells into fibrous tissue, myxo- matous tissue, cartilagenous and os- teoid tissue results in the more firm, April. 1922. ORIGINAL COMMUNICATIONS 173 more slowly growing, and -less malig- Though sometimes quite vascular, these nant tumors. It is therefore this fun- tumors do not pulsate. Fatty and mu- damental characteristic of differentia- coid degenerations may take place, also tion of the fibroblasts or spindle cells there may be hemorrhage, necrosis, and which has given rise to the more com- cyst formation in the tumor mass, plex histological distinctions between (b) Telangiectatic bone sarcoma, cen- sarcomas, and is exemplified in the tral osteogenic sarcoma, bone aneurysm, terms, spindle cell sarcoma, large round and malignant bone cyst are terms de- cell and small round cell sarcoma, fibro- noting the same lesion, osteogenic sar- sarcoma, myxosarcoma, chondrosarco- coma arising in the medulla or mar- ma, osteosarcoma, and combinations of row canal of the bone. There is con- these as osteo-chondro-sarcoma, etc., siderable variation in the character of when as a matter of fact all are simply these central sarcomata, but they all degrees of differentiation in one and the develop from the fibroblast or spindle same process of growth. cell, and are rightly called central osteo- The three anatomical varieties of genie sarcoma. A peculiar feature of osteogenic sarcoma are (a) the fibrocel- many of the central sarcoma is their hilar sarcoma, because of the predomi- enormous vascularity and absence of nance of fibrocellular tissue, and is any bulk of tumor tissue, and thus the chiefly periosteal, (b) the telangiectatic difference in terminology which usually sarcomas, because of the overgi'owth in describes the predominant appearance, blood vessels, and is largely central. Some are called bone aneurysm because and (c) the sclerosing sarcoma, because of the very great vascularity of these of the exaggeration of bone production, tumors, which may pulsate and even and is periosteal or central. These dis- yield a bruit; also telangiectatic sar- tinctions are not always clear, and coma, because of the extensive develop- there may be combinations of them in ment of the blood vessels, which may the same tumor. be widely dilated into large sinuses. Fibro-cellular or Periosteal Sarcoma — Malignant bone cyst is the central sar- This tumor arises from the inner lay- coma characterized by the complete ab- ers of the periosteum, extends along sence of any bulk of tumor tissue. Also and encloses the shaft of the bone. It as in the periosteal sarcoma, there may has a sharply marked border, and be more or less production of intercel- cau.ses a relatively bulky, rounded, fusi- lular substance by the fibroblasts con- form or lobulated tumor lying outside sisting of fibrous tissue, myxomatous of the shaft, which long remains intact, tissue or osteoid tissue, and resulting Periosteal growths commonly reach a in tumors of a more firm and solid na- large size. While the integrity of the ture. But this seems to be of rather shaft is usual, the more cellular growths infrequent occurrence, the central sar- penetrate, erode and destroy the com- comas being more often characterized pact bone, and lead to spontaneous frac- by great vascularity and lack of real tures. According to the consistence, tumor tissue. These sarcomata very these tumors are soft, cellular and high- early destroy the shaft and infiltrate ly malignant, or firm and fibrous, or the soft parts, penetrating the marrow irregularly ossified. For a short time cavity for only a short distance. The there is encapsulation by the perios- absorption of the bone is rapid, and the teum, which may lay down a thin bony line of absorption though irregular is capsule. When this is broken through very sharp. Spontaneous fracture of- the tumor invades the muscles, fascia ten is the result. In some cases the and other soft parts. A characteristic periosteum is displaced outward, and feature of periosteal sarcoma is the succeeds in laying down a thin shell of bony trabechulae which radiate from bone. There is not any expansion of the shaft of the bone into the tumor, the bony shaft in these tumors. The It does not cause expansion of the shaft majority of central tumors are not of as noted in the giant cell sarcoma, this type, but are the giant cell type 174 SOUTHERN MEDICINE AND SURGERY April, 1922. which is relatively benign and not never gives rise to metastases, and is osteogenic. The differential diagnosis generally agreed to be benign. Failure between the two is often difficult. to distinguish between this benign (c) Sclerosing osteogenic sarcoma is process and the malignant, less frequent the type in which there is a production central sarcoma has resulted in the of much dense, solid bone, sometimes needless sacrifice of many limbs. (The forming the bulk of the tumor. A large constant benignancy of this tumor has portion of the end of a bone is convert- led some observers to class it among ed into a solid mass of dense almost the inflammatory lesions of bone, while ivory-like bone, obliterating the mar- others do not consider it among the sar- row cavity, and causing a fusiform coma but simply use "Giant Cell Tumor" swelling. Blood vessels are scanty, and to specify this particular type of le- yet metastases occur. This tumor is of sion.) There is sometimes a good deal a long clinical course, and there are of variation in bone absorption and rate clinical and anatomical grounds for rec- of growth in these tumors, but they ognizing it as a specific type. have never been known to yield metas- The structure in general of osteogenic tases. Rarely they may penetrate the sarcoma varies as already noted accord- bony capsule and spread through the ing to the differentiation of the fibro- soft parts. At times they present mul- blasts. In the more malignant tumors, tiple tumors. In structure the giant the cells are closely packed together cell sarcoma is composed largely of and of irregular form, some spindle and numbers of giant cells of the foreign some round, either one of which may body type supported by a loose stroma predominate, and the intercellular sub- of fibrous tissue and spindle cells. Blood stance appears only as a scant trace, or vessels are numerous, and the tumor is completely absent. Many blood ves- quite vascular. sels are present. In the more slowly 3. Myeloma is a specific malignant tu- growing sarcomas the spindle and round mor of the bone marrow. The involve- cells will be much less numerous, the ment of the bone is often diffuse, and intercellular substance predominating, the development from multiple foci. In or even present in great abundance, and structure it is composed of closely will be seen to consist of fibrous, myxo- packed plasma cells. It is a relatively matous, cartilagenous, or osteoid tissue, rare tumor, and a fatal termination is or any combination of these. The vas- usually the result. (Myeloma has also cularity of these tumors is poor. A been known as myelogenous pseudoleu- particular characteristic of the perios- kemia, multiple sarcoma of bone mar- teal spindle cell sarcoma is the produc- row, and mollifies ossium.) tion of bone or cartilage. 4_ Endothelioma, occurring primarily 2. Benign giant cell sarcoma, chronic j„ ^ ^one has not been permanently es- hemorrhagic osteomyelitis, giant cell tablished, and the diagnosis requires tumor, etc., is perhaps the most pe- j^l caution, and rigid elimination of cuhar and interesting condition affect- outlying primary foci, as small carcino- ing the long bones, and has long been a ^^^ ^f ^he stomach, thyroid, prostate, zealously studied subject. It occurs ^^^ particularly the adrenal and kidney, principally in the marrow cavity of the ^he presence of this tumor as a pri- long bones and causes an absorption of i^si^n is a rare possibility, the cancellous bone, and widening of ^. • • .t. , , 1 --i the marrow cavity, as the periosteum J^^f ^"^'^1 '' ^^^, "t ^1''.^''^ "^ lays down an advancing shell of new fhich one has to deal, and the earlier bone. It therefore typically causes ex- J^^^ ^^\\^«^ ^« recognized and treatment n , , , "^r^ ,, T -4- begun the greater the prospects of cure, pansion of the bony shell. In its gross ,, ° , ° 4. ^u 4- i. ^ xu „^ -4- ui 1, u • It IS unfortunate that most of the re- appearance it resembles hemorrhagic granulation material, is a soft, reddish, corded cases of bone sarcoma have come jelly-like tissue. There is seldom any to treatment only after the symptoms tendency to invade the soft parts, it have been present months or years. April, 192 2. SOUTHERN MEDICINE AND SURGERY 175 (a) Symptoms— Trauma is generally atrophy that is seen in tuberculosis, thought^to plav a particular part in the These are the symptoms most com- development of the symptoms, but any monly met with. Trauma followed by positive knowledge as to how it acts is persistent localized pain, and later lacking. It is certainly true that in swelling, without temperature, muscle many of the histories the symptom of spasm or atrophy, suggests the possi- onset begins after some local trauma to bility of a cyst or tumor. It is to be the limb. urged that invariable pain in a bone near The first conspicuous symptom of a joint, even without swelling, without bone sarcoma is pain. It is the "earliest tenderness, or any other local evidence and most important sign of sarcoma of of disease should not be treated as the lon<^ bones," remarks Coley, and "rheumatism," neuritis, neuralgia, etc., Bloodgo'od urges that in "all bone tu- but demands to be followed carefully mors Vin is the predominant symp- with X-ray examinations, torn." The pain is of a deep and boring The duration of the symptoms may character and often present weeks or have an important bearing on the in- months before there is a palpable tu- terpretation of the case. If it is more mor or the X-ray discloses the evidence than two years since the symptom of of a new growth. These patients are onset, pain or swelling or pathological not unusually treated for "rheumatism," fracture if the lesion is central, the chronic arthritis, etc. With a previous probabilities are that it is a giant cell history of trauma, and a subsequent sarcoma or a benign bone cyst. In the persistence of marked local pain, there periosteum, a long duration of symp- is strong possibility of a bone lesion, toms means a slowly growing, less ma- and an X-ray examination should be lignant tumor. urged Too often perhaps we fail to (b) X-ray is an invaluable means ot make use of this means of diagnosis, recognizing and interpreting bone sar- probablv because there is no obvious coma. Periosteal sarcoma when well appearance of local disease, and accord- developed can readily be recognized by ingly very early lesions escape recogni- the X-ray character, but when very ^io„ early may be easily confused with Following the pain by a variable chronic inflammatory ossifying perios- length of time, depending upon the de- titis. In the well developed case one gree of malignancy of the tumor, there sees a rather dense shadow about the is swelling. In periosteal sarcomas this shaft of the bone, sharply localized, and may be very great. In central sarco- what is most distinctive are the trabe- mas it is not so large, and usually chulae of new bone formation radiating means that the growth has perforated outward from the shaft into the tumor, the bony shell, and begun to infiltrate The shaft may or may not show evi- the soft parts. Exception to this is dence of destruction. In the central tu- found in the giant cell sarcoma, which mors, the difficulties are more marked, long remains confined to the bony shell, because of the frequency of benign le- and produces swelling by causing ex- sions in the marrow cavity. This also pansion on the end of the bone. is the common location for the giant In central growths, or in periosteal cell sarcoma, a benign, non-metastasiz- which have eroded and destroyed much ing, curable disease, and it is higniy of the shaft, pathological fracture at essential that it be recognized as such, times occurs. A fracture received as In the central sarcoma, one sees an area the result of a very trivial injury al- in the end of the bone of marked ab- ways suggests the possibility of a bone sorption, with abrupt and sharply de- cvi or tumor fined limits, and a thinned out, but not impairment' of function is also at expanded cortex. The Periosteum may times a symptom, particularly in the or may not be laying down a thin shell leg, and limping occurs. There is, how- of new bone Ultimately the tumor ever, never the muscle spasm and breaks through the thin sheU of cortex. 176 SOUTHERN MEDICINE AND SURGERY April, 1922. and infiltrates the soft parts. In the ferent individuals. Pathologists will not giant cell sarcoma there is commonly always agree in regard to the histology, marked expansion of the cortex without and it is therefore important that sev- perforation. A bone cyst is the only eral skilled in the microscopic appear- other sort of lesion that gives anything ances of tumors be allowed to study the similar to this picture. In the giant sections. Yet in the majority of the cell sarcoma there is usually a charac- cases the clinical features, the X-ray teristic mottling in the area of rarified characteristics, the macroscopic and bone. microscopic appearances will establish (c) Exploratory incision in order to an accurate diagnosis, make a diagnosis is recognized at the Treatment depends on the diagnosis, present time as not only justifiable but and is planned to meet the needs of the indicated. Years ago there was some individual case. Immediate amputation difference of opinion regarding the wis- in all cases of sarcoma is obsolete treat- dom of this procedure, but so far as I ment, and results in the unnecessary can learn, most all authorities are now sacrifice of limbs. Exarticulation, am- agreed upon this method. Coley re- putation, local resection, curettage, ra- marks, "I still believe that in cases in dium combined with Coley's toxins rep- which there is any reasonable doubt of resent the extremes of treatment, the diagnosis, the advantages of an ex- In periosteal growths amputation is ploratory operation greatly outweigh the rule in the majority of cases, and the disadvantages." Bloodgood was per- exarticulation is demanded only in cer- haps the first to urge it, and most others tain very malignant and widely infil- have followed the plan. By this method trating cases, or when the tumor in- the surgeon is able to inspect the gross volves the upper end of the humerous appearances of the tumor, and deter- or femur. The figures of Jenckel seem mine the type and possible malignancy, to conclusively prove that in sarcoma of Further, sections may be removed for the lower end of the femur, exarticula- microscopic study, and a more exact tion at the hip joint gives no better diagnosis obtained. With the findings results than high femoral amputation, from these, proper treatment can be This I think may be applied to other more accurately instituted, and the his- bones — when high amputation fails, ex- tological type certainly gives us a great articulation can promise little or no bet- help in making a prognosis. The dan- ter results. Regardless, however, of ger from metastases after exploratory the extent of the operation, the result- operations is slight, and the value of ing fatality is so high, with a possibil- knowing the type of tumor one may be ity of cure in only 4 per cent of cases, dealing with far outweighs the risk. that one form of treatment seems no The tremendous significance of an ac- better than another, and this fact has curate diagnosis in sarcoma of the long led some surgeons to favor more con- bones should be well recognized, since servative methods of treatment. Chief it is to determine the plan of treat- among these is Coley, who treats all ment, and materially aid in forecasting periosteal sarcomas conservatively by the results. There is so much variation the use of the mixed toxins of strep- in the degree of malignancy of bone tococcus and prodigiosous, sometimes sarcoma, particularly when the giant combined with radium. In 1919, he re- cell type is included, that the plan of ported a series of cured cases, some of treatment can only be indicated clearly which were cured alone by the use of after a reasonably sure diagnosis is the mixed toxins, others by the com- made. With the diversity of these tu- bined use of the toxins and radium, mors, their differing manner of growth Radium alone has cured no cases. He and bone destruction, there naturally thinks that better results could be gain- are some cases that will remain obscure ed from this treatment if begun earlier in spite of our efforts. The same tumor in the progress of the disease. The ra- will vary in different bones, and in dif- dium is applied locally after as much of April, 192 2 ORIGINAL COMMUNICATIONS 177 the tumor as possible has been remov- locally after all tumor tissue has been ed. The toxins act as the systemic cleared away have cured some cases, remedy. ' and is advocated by Coley. In the treatment of the central Bone sarcomas are perhaps the most growths exact diagnosis of the type of highly malignant of all tumors, and tumor, the degree of malignancy, and metastases occur early. The majority the progress of the disease are essen- succumb to internal metastases, chiefly tial in deciding the method of treat- to the lungs. Perhaps the high mortal- ment. Any one of several forms of ity rates are in part due to the fact treatment may be indicated by the type that very few cases are recognized in of tumor. the beginning, and when first seen are In the giant cell sarcoma curettage of far advanced with internal metastases the bone cavity, and cauterization with already present. Our only chance, then, carbolic acid and alcohol promises a until something more is known concern- complete cure in the great majority of ing the real etiology, must depend on cases. When the tumor, as occasion- the early detection of the malignant ally happens, has broken through the process. Fewer diagnoses of that hazy shell of bone and filled the soft parts, diseases known as "rheumatism," more there is no contraindication to the con- frequent use of the X-ray, and explor- .servative treatment (Bloodgood). Lo- atory incision would be of great advan- cal resection then may be the most that tage. is necessary, and curettage followed by The prognosis is generally bad, but the use of carbolic acid and alcohol may the widest extremes are represented in be sufficient. If not all of the tumor is the different sarcomas. The age of the removed from the .soft parts a local patient, the duration of the disease, its recurrence will take place, but even un- rate of progress, the particular bone der the.se circumstances two or three affected, the completeness of the opera- curettements will eradicate the disease, tion, and above all the structure and This tumor never gives rise to metasta- essential malignancy of the tumor must ses, and recurs locally only when in- all be considered, completely removed, and is therefore benign. Barrie considers it an inflam- matory lesion and calls it "Chronic NITROUS OXIDE-OXYGEN ANALGE- SIA AND ANAESTHESIA IN Hemorrhagic Osteomyelitis." Bloodgood speaks of it as the "Giant Cell Tumor." The great thing about this lesion is to OBSTETRICS* recognize it, and not to confuse it with malignant central osteogenic sarcomas, ^^ ^- ^^"^^^>' ^^'^' ^•^- , a differentiation that is bv no means Obstetrician, Sarah Leigh Hospital and always easy. ^'"''^"'^'^ Cnttendon Home. In the treatment of osteogenic cen- To my mind there are at least three tral sarcoma the lines of procedure are important reasons why we need anaes- very much as in the periosteal, except thetics in obstetrics. They are: first, that in some cases, seen early, local re- shock is prevented or minimized by section of the bone may serve, and the their use; second, less nervous energy limb saved. Resection, however, should is expended during the labor; and third, be confined to small, slowly growing, the average patient demands it. encapsulated central sarcoma, which Realizing that an anaesthetic is ad- have not perforated the periosteum and visable, how should we make our choice infiltrated the soft parts. In the rap- as to the one best fitted for use in ob- idly growing, cellular tumors amputa- stetrics? The answer to this is: select tion is the indicated treatment. But here again prospect for cure is discouraging, *Read before the Tri-State Medical Associa- and only 8 per cent of the cases survive, tion of the Carolinas and Virginia, Norfolk, Coley's toxins and the use of radium Va., February 22-23, 1922. 178 SOUTHERN MEDICINE AND SURGERY April, 192 2 the one that is safest for the patient, cost of the gas amounts to very little, and that will give the greatest relief The Clark and the Gwathmey machines over the longest period of time. Of the are both practical and are as nearly fool- anaesthetics in common use, nitrous proof as would be possible. Personally, oxide-oxygen seems to best meet these I use a Clark, principally because it is requirements. easy to manipulate, can be placed in a Probably other is used most often in small container and be transported read- obstetrical work at the present day and ily, and is therefore available for use it serves a very useful purpose. Its in the home as well as in the hospital, administration is not devoid of danger. Most of the later models are equipped however. We all know that the toxicity with a valve that can be manipulated is not to be made light of, and that any by the patient. She is instructed to acute respiratory disease is a contra- press upon the thumb-piece whenever indication for its use. When begun in she has a pain; by thus pressing this the early second stage and given in a valve, the flow of gas is turned on. sufficient quantity to really give any There is no danger of her getting too material relief from pain, ether almost much in this way, because should she invariably lengthens the interval be- begin to relax, the pressure on the valve tween the uterine contractions as well will naturally cease and the flow of gas as weakening their force. Ether is ab- stop. A point of warning just here: do sorbed very much more rapidly than it not leave the patient alone with this ap- is excreted, therefore when given for pliance, which is not intended to take any great length of time there is likely the place of an anaesthetist, to be a decided toxic effect upon both It might be well to outline just here mother and child. the routine which I have followed. Most As to chloroform: it is pleasant to of my cases have been given from i/g take, it is both absorbed and excreted to 14. grain of morphine sulphate some- more rapidly than ether, but remember- time during the labor. Two points of ing the dangers of chloroform poison- advantage are gained by so doing: ing and that the border-line between First, it tends to act as a sedative to light and deep anaesthesia is so easily the patient and I believe the relaxation crossed, it should be considered unfit for due to its use, causes a more rapid dila- general use. tation of the cervix. I try never to give All of these undesirable effects of morphia, however, nearer than six ether and chloroform can be eliminated hours before the expected delivery of by the use of nitrous oxide-oxygen. The the baby, because of the toxic effect it gas is excreted practically as rapidly as might have upon the child, absorbed and therefore produces no After the administration of nitrous- cumulative effect. It stimulates rather oxide is begun I make it a point to re- than inhabits the contraction of smooth main near the patient, or have someone muscle fiber, which means an increase who is competent to give it, be there in rather than a diminution of the uterine my stead. This rule should always be contractions. The interval between pains carried out, and when it cannot be done, is shortened and the force of the pains the administration of nitrous-oxide is increased slightly, with the net result should not be attempted, of a shorter labor. Combined with The lying-in room is kept quiet, warm oxygen, nitrous-oxide can be given dur- and well ventilated, unnecessary con- ing each pain throughout the labor, versation is not allowed, and the confi- Nausea is the exception rather than the dence of the patient is insisted upon, rule following its administration. She is made to realize that her suffer- There are several types of apparatus, ing is going to be kept at a minimum, especially designed for its use in obstet- and that her co-operation is necessary rical work ; the price of any of them is if the best results are to be accomplish- easily within the reach of all, and when ed. It is to the advantage of both the given with any degree of economy the patient and the obstetrician that the April, 1922. ORIGINAL COMMUNICATIONS ^ 179 woman be familiarized with the salient 5. That it will give the woman a prac- factors in the labor. The patient is in- tically painless labor without the dan- structed to tell you when the contrac- gers of such drugging as is necessary tions are sufficiently painful to require in the so-called "Twihght Sleep." some relief. The administration of the Bibliography gas can now be begun, with the on- Anaesthesia in Obstetrics: P. Appleton, coming of each pain. From four to Boston Medical and Surgical, Volume eight inhalations are required to pro- CLXXXII, 1919. duce analgesia, the dosage varying with Anaesthetics in Obstetrics: Special Refer- different individuals. When the pain ence to Nitrous-Oxide, R. C. Coburn, Medical has subsided the anaesthetic is stopped Record, Volume XCVII, 1920. until the beginning of the next pain. Advantages of Nitrous-Oxide-Oxygen in After a few pains the average woman Labor, C. E. Turner, American Journal of Ob- is able to anticipate the contractions by stetrics. Volume LXXX, 1919. a few seconds and by so timing the ad- Obstetrics, a Two Man's Job: p. Appleton, ministration of the gas, the majority of Rhode Island Medical Journal, July, Aug., women can be delivered harmlessly and Sept., 1921. practically painlessly. As the labor pro- Some Manifestations of the Danger From gresses, the quantity of gas can be cor- Labor (Mental): By C. Hollister, Judd. Jour-^ respondingly increased, so that the de- nal of Michigan, State Medical Society, June, livery of the child is made under an- 1921. aesthesia. Where complete relaxation Use of Nitrous-Oxide-Oxygen Analgesia is required it is necessary to have a Anaesthesia in Obstetrics: T. B. Sellers, New competent anaesthetist to depend upon, Orleans Medical and Surgical Journal, August, and whenever one is not available, I feel 1921. it a safer procedure to resort to ether Modem Methods of Conducting Labor: A. at this stage. L. Gray, Journal Missouri Medical Assoc, The question of the anaesthetic is Oct. 21. vital in obstetrical operations, and it is in this class of cases that nitrous-oxide SOME DISTURBANCES IN PERNICI- oxygen serves one of its most useful ^^^g ANEMIA OTHER THAN purposes. In breech extractions and forcep deliveries it is ideal while in con- BLOOD CHANGES* ditions that require Caesarian Section ^^ Hgn^,y A_ Christian, M.D., Boston. it is the anaesthetic of choice. It is needless to say that the operative risks Mr. President and members of the of general surgical conditions which Tri-State Medical Society of Virginia may complicate pregnancy, are mate- and the Carolinas, I am going to talk to riaily lessened by its use. you this afternoon on a somewhat trite Considering these facts, based upon subject. It seems to me that it is de- actual experience during the past two sirable from time to time to take up years, together with the favorable re- discussions of trite subjects because so ports that have appeared in recent lit- often we tend to overlook certain fea- erature, the author feels that he is jus- tures as a result of having our atten- tified in arriving at the following con- tion too much focused on some detail of elusions: the subject. It seems to me that this 1. That nitrous-oxide-oxygen is the is true with pernicious anemia. Here anaesthetic of choice in obstetrics. our attention has been focused so in- 2. That shock is prevented or mini- tently on the details of changes in the mized by its use. blood that we tend to lose sight of very 3. That it can be administered prac- important other disturbances that go to tically throughout the labor. 4. That its cost is not inhibitory and *Read at the Norfolk meetmg of the Tn- that it can be given in both the hospital State Medical Association of the Carolinas and the home. and Virginia, February 22-23, 1922. 180 SOUTHERN MEDICINE AND SURGERY April, 1922. make up the clinical picture of pernici- in this same series of cases in which a ous anemia. typical blood picture occurred in 77 per In hospital practice pernicious anemia cent a typical condition of the tongue seems to be a very frequent conditioji. was found in 65 per cent, a suggestive At the Peter Bent Brigham Hospital in tongue condition in 19 per cent and a Boston we ordinarily have from three normal apearing tongue in only 16 per to ten cases on the medical service at cent. one time and often we have more cases A second reason for emphasizing of pernicious anemia than of any other some of the features of pernicious ane- single disease with the exception of mia other than the blood changes lies chronic cardiac disease, syphilis in its in the fact that these other changes not various manifestations and chronic ne- infrequently are found prior to the dis- phritis. Chronic tuberculosis is not covery of changes in the blood. For ex- treated in this hospital, so that no com- ample, absence of hydrochloric acid parison can be made with the frequency from the gastric juice may occur before of occurrence of chronic tuberculosis in the patient shows any anemia. We have hospital practice. actually observed it to be present in There are several reasons for empha- some of our cases as much as five years sizing these other features of pernicious before the patient developed evidence of anemia. One is that some of the other an anemia. In a similar way definite features of pernicious anemia actually central nervous system changes not in- occur more frequently than does the frequently antedate changes in the typical blood picture of pernicious ane- blood by months and sometimes even by mia. For example, absence of hydro- years. chloric acid from the gastric juice is a A third reason for emphasizing other more common finding in pernicious ane- features than the blood picture of per- mia than is the characteristic blood nicious anemia is that some of these picture. In a study of a considerable other features are so prominent that group of cases of pernicious anemia they lead to an incorrect diagnosis. For gastric analysis was made in 105 pa- example, not very infrequently a patient tients and in 104 free hydrochloric acid with pernicious anemia is sent to the was absent from the gastric juice. In hospital with the diagnosis of cancer of this same series of cases a typical blood the stomach made because gastric picture was found in 77 per cent, a sug- symptoms have been prominent, the pa- gestive blood picture in 18 per cent and tient is in the age period in which can- an atypical or normal blood picture in cer of the stomach occurs with fre- 5 per cent during the time of their stay quency and the sallow appearance of in the hospital. You will see here that, the patient suggests tumor cachexia, whereas approximately 100 per cent Of 125 patients admitted to our wards showed absent hydrochloric acid, only six had actually been operated upon 77 per cent showed blood changes that prior to admission on account of an in- would be typical enough in themselves correct diagnosis based on the promi- to justify the diagnosis of pernicious nence of gastrointestinal symptoms in anemia. the case. Three of these had been con- Even so easily observed a condition sidered ulcer of the stomach, one ear- as the condition of the tongue presents cimona of the stomach, one was thought characteristic changes with almost the to have gall stones and one was thought frequency of the occurrence of the char- to have cholecystitis, acteristic changes in the blood picture. A fourth reason for emphasizing At the present day it is distinctly out these other features lies in the fact that of style to observe the tongue and to the blood picture during remissions may place much importance upon the be entirely normal and so the study of changes found. However, the condition the blood would not give any evidence of the tongue is often very helpful in of the existence of a pernicious anemia, the diagnc.-is of pernicious anemia and In contrast to this some of the other April. 1922 ORIGINAL COMMUNICATIONS 181 features persist even after the blood of gastric discomfort and indigestion, has returned to normal. For example, It seemed to me that the correct diagno- the absence of free hydrochloric acid in sis should have been made in this pa- the gastric juice remains and usually tient before any blood examinations the central nervous system disturbances were made and the blood examinations persist during the remissions. should simply have served as adding The question of wrong diagnosis in another feature increasing the probabil- cases of pernicious anemia is of much ity of the diagnosis, interest. It would seem that the incor- Now, let us turn briefly to these other rect diagnoses occur most frequently features in pernicious anemia and see owing to failure to obtain a complete what they are. With regard to the and careful history and in this way central nervous system, we very fre- overlooking important features in the quently obtain a history of sensory dis- ease. The other reason for an incor- tubances; particularly do the patients rect diagnosis lies in concentrating at- complain of tingling or numbness in tention on features suggested by the their fingers. Not so frequently but history and failing to observe other very often they complain of the same changes that are present in the patient, disturbance in their feet or they say How this occurs is quite well illustrated that their feet have a numb feeling if by a patient whom we saw during the they stand upon them and sometimes past year sent into the hospital with a they feel as if they were standing on a diagnosis of cancer of the stomach. In cushion instead of a hard surface. Very the hospital a careful history was ob- often there are disturbances to be made tained, and it was so characteristic of out in the reflexes. The most common the disease that it seemed to me that change perhaps is a decreased bone sen- the history almost alone justified the sibility made out by use of the tuning diagnosis of pernicious anemia. With a fork. Quite often these patients have view to testing out this idea on a group decreased knee jerks and a smaller num- I presented the history to my third year ber have increased knee jerks. Some students with the patient lying in the of those with decreased knee jerks have amphitheatre in bed in front of them, incoordination and represent a fairly While I was giving the history they had definite tabetic type of symptom com- an opportunity to observe the face of plex from areas of sclerosis in the pos- the patient as he was in bed in front terior columns of the spinal cord. Of of them. Having finished the history I those with increased knee jerks some asked the class to make a diagnosis of have markedly increased reflexes, in- the condition. A very large per cent of eluding an ankle clonus and patellar the class promptly answered pernicious clonus, and those represent the group anemia : in other words, a third year with sclerosis in the lateral columns of class of students were able to recognize the spinal cord. Sometimes these pa- the disease by hearing the history and tients have a markedly increased spas- merely seeing the face of the patient, ticity of the muscles and occasionally It seemed to us that the physician who a cross-legged progression is found m had sent in this patient had failed tp this type of cord involvement. It is of make the correct diagnosis because he interest that whereas the sensory dis- had taken only one part of the patient's turbances are more often found early historv, nameiv, the gastric history, and in the upper extremity the more mark- had failed to ask about other features ed changes in reflexes occur in the lower of the case. In this particular case the extremity. patient gave the historv of tingling sen- Of the gastrointestinal symptoms dys- sations in his finger tips and in his pepsia, distress up to actual pam, loss feet, and also the history of periods in of appetite, nausea and diarrhea are which he felt very weak and listless and often described in the history. Some- at other times felt fairly strong. Dur- times the diarrhea is of the anacidity ing much of the time he did complain type with one or two soft rather bulky 182 SOUTHERN MEDICINE AND SURGERY April, 1922. stools, and this condition not infre- quently can be corrected by giving hy- drochloric acid, supplying the deficiency in the gastric secretion. In other cases the diarrhea is of the inflammatory type and appears to be similar to the diarrhea that we find in subacute and chronic inflammatory lesions of the colon. As has already been intimated, changes in the tongue are very fre- quently found. Sometimes there are sensory disturbances. The patients complain of numbness of the tongue or a tingling sensation or that the food "bites" the tongue. Sometimes the tongue becomes so sensitive that eating is markedly interfered with. Some pa- tients are unable to eat salty food, oth- ers cannot bear vinegar, and in others condiments of any sort are very irri- tating. In some cases the sensory dis- turbances are unaccompanied by any evidence of change in the mucous mem- brane of the tongue. In other cases the tongue has a beefy red, slightly swollen appearance and this is apt to be most marked along the lateral margins of the tongue. Not infrequently superficial ul- cerations appear at the edges of the tongue and very often these are ex- tremely sensitive. As time goes on the papillae of the tongue tend to atrophy, and finally the tongue becomes smooth, glossy and pale, and occasionally deeply furrowed. It is this latter appearance of the tongue, namely, smooth, glossy, pale tongue, that is regarded as very characteristic of the disease. Fever is a feature of pernicious ane- mia that very frequently is overlooked. If the blood count falls to a low level almost invariably the patient shows some elevation of temperature above the normal. Occasionally the febrile reaction is such a marked one that the patient may be misdiagnosed as having some acute infectious disease, for ex- ample, typhoid fever. In these cases with fever the fever promptly disap- pears when the blood count goes up. One result of increasing the blood count by transfusion is a disappearance of the fever. It is rare to have fever when the blood count is above 1,500,000 red blood cells. The color of the skin in these patients is often very characteristic. It is a combination of pallor with a slight lem- on yellow tinting of the skin and not infrequently of the sclerae. It is this color in association with abdominal symptoms which leads to the incorrect diagnosis of gall bladder disease or cancer of the stomach. As has already been intimated, many of the patients are in the same age period as when can- cer occurs. In our own series the aver- age age of the patients at the time of their admission to the hospital was 51 years of age. It seems to me that pernicious ane- mia should be regarded as a general disease, not as a blood disease; a dis- ease in which a variety of symptoms and signs appear, among which anemia is only one, and often other features of the disease are just as prominent, if not more so, than the anemia. THE TREATMENT OF THE EMO- TIONS IN YOUNG PEOPLE By Tom A. Williams, M.B.C.M., Edin, Washington, D. C. We must define what we mean by emotions. It may be considered as a veaction in the body without any re- action upon the environment. Emotions are not under the control of the will. However, we have the power of choos- ing the impressions which we wish, and these together with similar impressions are elaborated into perceptions, which are abstracted into ideas. This we call thinking. Each thought contains both pleasant and unpleasant elements and it is merely a matter of attention which elements shall predominate, and the one predominating determines the emotions, so the emotions can be determined by intelligence. Since every emotion is accompanied by physical changes it is important that a young person should acquire the right kind of emotions. We are familiar with the sagging back, the lack of ambition, which denotes habitual bad feeling, con- stipation, slow breathing, interfering April. 1922 ORIGINAL COMMUNICATIONS 183 with the internal organs. When the tone is optimistic the signs are bright eyes, brisk walk, active breathing, good digestion, active mind. The way of looking at things is of utmost import- ance as has been proved without doubt by countless cases. Long ago Shakes- peare made Hamlet say, "There is noth- ing good or bad but thinking makes it so." A despondency due to disbelief in recovery has caused many a death from disease. Particularly is this so of prim- itive minds. So that parents cannot be too particular about the way they deal with the feelings of children. If they are brought up with too much particu- larness of some things, it develops a twist of mind which hinders the chance of success in life and interferes with social adaptation, which brings further ill health. We know infants taken from a foundling hospital to a home have shown betterment of health. This is in great part due to their response to the kindness which they have in a home, but which they did not have in a found- ling hospital. It is astonishing to those not con- versant how early a child grasps re- sponsibility and self-criticism and con- trol. For instance, a boy of two and a half had a habit of throwing a knife at a domestic. When he was seriously spo- ken to by his mother he restrained for three weeks ; then one night an impulse got the better of him and he threw it again. He came at once to his father and mother and said: "Daddy, thrash boy, boy threw knife." An investiga- tion as to the truth of this statement was made. After discussion, it was decided to accede to the boy's request and he fetched his slipper and was given the usual punishment. This was a self-imposed punishment. It indicat- ed that he had a strong feeling of the right thing to do ; that when he had given way he was thoroughly ashamed of his act and knew that amends must be made. This very strong feeling was so great he even imposed upon himself that which he greatly detested, namely, a whipping. No recurrence of giving way to this impulsive emotion has hap- pened for eleven years. This boy's at- titude was a love of justice, honesty, courage, and right action in general, and to this one thing in particular, the emotional tone being developed toward a desire for justice, although the boy was only two and a half years old. Parents should never lose sight of the fact that in a child who is encouraged in expressing beneficial emotion and has the proper training, the emotions as an adult will take care of themselves. We doctors, however, have to deal with the emotions of people which have made them sick; and the question of rectifying the emotions presents itself. I have under observation two young women in a finishing school in Wash- ington, in each of whom there is a lack of adaptation. In the one case it is the desire for affection which is shown somewhat impulsively and meets with rejection in consequence. The girl, how- ever, has her social adjustments much helped and is able to continue in school, much to her benefit. The other is hypo- pituitary and has been under treatment for two years; she was adjusting badly, wanting to leave school and go on the movie stage, being so beautiful a child. It was necessary to penetrate into the girl's character, a very difficult thing to do, as she is very uncommunicative; and then to make a disposition so that she would acquire different ideals. In that way adjustments were made. When that is done, emotions take care of themselves unless they have become habits, in which case they must be dealt with psychologically. In other cases difficulties are bodily inadequacy or disease such as created by anemia. It is frequent in young peo- ple to find a low red blood count to be the cause of a general inadequacy at work and play. This recovers spontane- ously after the anemia has been cured unless it has led to faulty habits of do- ing, thinking or adaptnig. If so, these must be reconditioned, a simple and rapid matter in skilful hands but in danger of being sadly bungled by the unskilful. Among the emotions jealousy is a fre- quent cause of disturbance in the young. It is quite easily dispelled if dealt with 184 SOUTHERN MEDICINE AND SURGERY April, 192 2 wisely and explained to the child. I they entered the room. The result was might cite a number of cases. A very a state of ill health, so that she was frequent emotion is that caused by ex- supposed to be a frail, ailing child, cessive diffidence, nearly always induced When the fear was gotten rid of, which by injudicious management. A young took about two weeks in Washington, woman because she was said to have a she was able to go to school, which she large mouth endeavored to talk with a ^ad never been able to do before, and small mouth and thus disfigured herself ^^^ ^^^^^^ ^ g^r^^g^ vigorous young and her speech so that she was unable to take part in the dramatic exercises woman. (Management Nervous Chil- which would have been beneficial to her. dren, N. Y. Med. J., Jan., 1916). In that way her whole life was distort- ^jj ^j^^gg instances (and I could give ed and through a series of misfortunes ^ ^^^^^ ^^.^ ^.^^ ^^^^. she lost her life. ,^, ^ itj^^- -u^ pies of how not only disadaptation but In another case a young man was im- ^^^^^.^ .^j ^^^^^^ ^^^ ^^ .^^^^^^^ ^ bued with the idea he could not learn , i , • the classics and for this reason he led emotions which are purely psychologi- the life of an artist, for which he was cal. Such disabilities are being remov- unfitted, whereas he would have excell- ed currently. The patients are taught ed in science, which required prepara- to adjust themselves to life, the health tion in the classics. This was through ^^^^ perfectlv well, and they are able the feeling of diffidence which he had, , ,, ■,•..'. ^ v^+u .,,,,, , , p , , not only to ad]ust themselves but to be induced by the contempt of an older j- j , . , brother ^^^^ ^"^ strong. We have simply to consult the experimental evidence which In another case the son of a senator , j n j. -i • i v , J U4-- V 4- ^-u• was created for us so strikingly by who was so doubting about everything o j ^^ he did he could not dress himself in Pavlow's dogs, to show how very in- the morning— thirty years of age and tense may be the modification of secre- still had to be dressed by his father or tions by the emotions imposed from mother or both. Sometimes it would without. In human beings emotions take two or three hours to get him ^^^^ ^^ ^^^^ ^^,^^ ^.^^.^^ j^ dressed. This man had been made dit- ,., ,, . • , ^ j. i i. fident by the over-protection of his par- ^^^^^^y the emotional state has been ents. When gradually I induced them induced generally m childhood by a set to relax their solicitude he developed so of sensations which are elaborated into that after two years he was able to perceptions, which are elaborated fur- handle himself in life by managing a ^her into ideas, memories, which carry ^^ * with them painful, distressing emo- Of course, the commonest of all emo- tions. When these are called into being tions is fear. (See Psychogenetic Dis- ^y stimuli from without or by the rumi- orders in Children, Amer. Journ. Med. ,. ^ ,, • ^ 4? -^.i,- u o • ^r^^r.^ T,T -n I. XI natious of the mmd from withm, by Sci., 1912.) Many will remember the , , , , . ,^ , boy who feared wild animals would dreams, or by the body itself, we have jump on his back, whose impulsions the disturbances which make the person were taken for epilepsy. On interview unfit, and which gives rise to a failing led to control of his impulsions. Also of health, the cause of which is some- a little girl who would sit on the stairs ^-^^^ ^^^ perceived because the family for hours because she was ashamed to ^ • , -, . • ^.i, t^-u r, ^ -J X + u /I „i or friends are used to seeing the child say she was afraid to go to bed alone. She sat on the stairs until she heard like that: They think it is his nature, the other members of the family come when it is really an emotion which can to bed, when she would run and jump be removed in a short time by a skilful into bed an^ pretend to be asleep when neurologist. April, 192 2. ORIGINAL COMMUNICATIONS 185 COLITIS* 4 — Mechanical irritants — scybala, „ „, , „ XT ^ calculi, foreign bodies. By A. T. Russell, M.D., Wednell, N. C. „, ' ^ ^ i j 4. The secondary form may be due to: Synonyms — Acute Dystentery; Ulcer- i — Infections of various sorts — gen- ative Colitis ; Bloody Flux. eral or intestinal. Z)e/jw/f/o7«— (Monographic Medicine) 2— Extension from adjacent inflam- An acute inflammation of the intestine ; mations. the intestine may be involved as a Pathologic Anatomy — In the catar- whole; or the small, or more often the rhal form. The mucus membrane and large intestine may be localized as a sub-mucus coat are swollen, congested, Duodenitis, a Jejunitis, an Ileitis, a and oedematous, and mucus is formed Colitis, a Sigmoiditis, or a Proctitis. in excess. The follicles are enlarged (Hughes) An acute inflammation of and may become ulcerated, the mucus membrane of the large in- Symptoms — May or may not be fever, testine; either catarrhal or croupous in The catarrhal form begins gradually character, followed in some cases with with diarrhoea, loss of appetite, nausea, ulceration, characterized by fever, tor- .and very slight fever, which continues mina, tenesmus, and frequent small for two or three days, when the true mucus and bloody stools. It may be dysenteric symptoms develop, to wit: sporadic, endemic, or epidemic, and oc- pain on pressure along the transverse curs in four clinical forms; i. e. : and descending colon, tormina or col- 1 — Acute Catarrhal. icky pains around the umbilicus, burn- 2 — Amebic or Tropical. ing pain in the rectum, with the sensa- 3 — Croupous or Diphtheritic. tion of the presence of a foreign body 4 — Chronic Dysentery. and a constant desire to expel it, or During childhood, the two parts of tenesmus. The stools for a day or two the intestines are usually affected to- contain more or less fecal matter, but gether, although in different degrees. they soon change to a grayish, tough, We will deal with the variety that transparent mucus containing more or frequently occurs in children all less blood and pus. The number of through the warm climate. stools varies from five to twenty or This is listed in Kerley as "Acute In- more in twenty-four hours. During the testinal Indigestion." It is far more tormina, nausea and vomiting may oc- important than the majority of the cur. The urine is scanty and high col- l)hysicians think, and the proper man- ored. The duration is one week, the agement of this disordered intestinal patient becoming emaciated and feeble, function is essential to the solution of There is a rapid loss of strength, thirst that most important problem — Summer and oliguria. In severe cases there is Diarrhoeas. It is more prevalent among collapse with cyanosis, and cold clammy bottle-fed children than breast-fed. skin (algid stage) ; in such patients, Etiology — The primary form is due symptoms of cerebral anemia (somno- to: lence, rigidity of the neck, convulsions, 1 — Dietetic Errors, i. e., irregular retraction of the eyes and fontenelles, feeding, over feeding, etc. tachycardia, and dyspnoea ( appear, 2 — Ingestion of indigestable foods, yielding the clinical picture described spoiled foods, or of very cold drinks, as "hydrocephaloid" in children, i. e., new potatoes, meats, greasy foods, Diagnosis — The diagnosis is entirely rancid meats, cold soda water, ice cream made from the symptoms and from an (containing corn starch and artificial examination of the stools. In acute co- coloring and flavors) . litis, the number of stools is large and 3 — Chemical irritants — drastic there is tenderness on pressure along purges. the colon, and mucus in larger masses (not bile stained )is visible. The di- TTn«nif.?Mif- "l^l"''-^."^o^? •^^^'It^J.'^%^^"' gcstion of meat and starch may be Hospital Medical Society. Raleigh, N. C, June ° . , , , •j_ ,^ • . %. 21, 1921. fairly good, despite the existence of co- 186 SOUTHERN MEDICINE AND SURGERY April, 1922. litis. The bloodstained stools, tenesmus, abdominal pain and the history will aid in distinguishing dysentery from the other enteric conditions. The variety of the disease may be recognized by the micro-organisms in the stools and the symptoms. In the etiological diagnosis, the anem- nesis must be considered and the body as a whole studied. We must rule out: 1 — Typhoid Fever (leukopenia, blood culture in bile-bullion). 2 — Acute Appendicitis (local tender- ness and muscle spasm, increased leuko- cytosis, more nausea and vomiting) . 3 — An Acute Dysentery (bacilliary, or amebic). 4 — The diarrhoeal attacks of Grave's disease. 5 — The intestinal form of Influenza. Treatment — The time to treat these cases is before the physician sees the patient. The reduction of the mortal- ity rests in the education of the mother to the point of realizing that a loose green stool is a danger signal. When it occurs, she is to give a dose of castor oil, two teaspoonsful, stop the bottle or breast, and give the baby boiled water or barely water until the physician can see the patient. Hygienic management is of the first importance. The effect of a change from the hot stifling atmosphere of a town to the mountains or the sea is often seen at once in the reduction of the number of stools and a rapid im- provement in the physical condition. The child should not be too thickly clad. Many mothers, in warm weather clothe their children too heavily. Bathing is of value in infantile diar- rhoea, and when the fever rises above 102.5° the child should be placed in a warm bath, the temperature of which should be gradually reduced, or the child is kept in a bath for twenty min- utes, by which time the temperature of the water is sufficiently reduced. Much relief is obtained by the application of ice cold cloth or ice cap to the head. Irrigation of the colon with ice water is sometimes favorable, but it has not the advantage of a general bath, the beneficial effect is seen, not only in the reduction of the temperature, but in a general stimulation of the nervous sys- tem of the child. Washing out the colon with physio- logical salt solution (roughly, one tea- spoonful to each liter of warm water) ihas a most soothing influence. This may be repeated once or twice each twenty-four hours. Other solutions are also suitable, such as one teaspoonful of tannic acid in two quarts of water; weak solutions of boric acid; 5% to 10% aqueous solution of fluid extract of krameria; weak infusions of camomile tea. If there is much straining or tenesmus, rectal suppositories contain- ing opium or belladonnae are useful. An injection of weak starch solution containing twenty drops of Tr. opium is an old and approved remedy to allay irritation of the lower end of the bowel. Dietetic Treatment — In the case of a hand-fed child it is important if possi- ble to get a wet nurse. While fever is present digestion is sure to be disturb- ed, and the amount of food should be restricted. If water or barley water be given, the child will not feel the depri- vation of food so much. When the vom- iting is incessant it is much better not to attempt to give milk or other articles of food, but let the child take the water whenever it will. Barley water or rice water is made by adding one heaping tablespoonful of rice to a pint of water in one vessel and one tablespoonful of barley to a pint of water in another vessel and boiling them down to one-third. These gruels are fed alternately. Medicinal Treatment — The medicinal treatment as given by different authors covers a very wide field. Kerley — In the Breast-Feel — It may be necessary to discontinue nursing for from twelve to thirty-six hours. The child is given one or two drams of cas- tor oil and barley water, to which one- half or one-fourth ounce of cane sugar is added to the pint. While nursing is discontinued the breasts should be pumped at the regular nursing hour so Hydrag. Chlor. Mit. gr. ii Nati Bicarb. gr. iv Ext. Pepsin gr. ii Sacharum Lactici gr. xl M. et. Div. Chart No. 8. Sig. One powder in hot water every Sig. Teaspoonful every two hours. Bismuth Subnit dr. iss Tr. Opil Camp. dr. i April, 1922. ORIGINAL COMMUNICATIONS 187 as to keep up the flow of milk and re- one tablespoonful of barley water every lieve the pressure. Rarely will other hour alternately. I give the patient a treatment be necessary. large dose of castor oil or a prescription In the Bottle-Fed — Greater caution as follows for a patient one year old. will be necessary. The management consists in continuing the carbohydrate diet, which the well trained mother has begun, until the stools approximate the normal, which may necessitate an absti- nence from milk for three or four days, by which time it may usually be re- half "hour. sumed. In resuming the milk, it should ^^^^^ ^^^ ^^^^^^^ ^^^^ ^^^^^ ^^^^_ always be given m reduced quantities ^ ^^j ^^ ^ ^^^^^^ ^^ ^^^ ^^ j ^.^^ ^ for the firs day. pne-half ounce of prescription about like the following: skimmed milk may be added to every Bismuth Subnit dr. iss second feeding or to every feeding of ^r. Opii Camph. dr. i gruel. If it is well digested and causes Aq. Menth.'Pip. oz. ii no return of the diarrhoea the amount Aouae as oz iii of milk may be increased tentatively ^t 1 c i every day or two by the addition of one- half ounce to each feeding. Osier — Recommends bismuth in large doses as much as two drams a day in an infant one year old. The Gray Powder Ext. Mystrica gr. xxiv has long been a favorite in this condi- Aquae Menth. Pip. oz. ii tion and may be given in half grain Aquae qs. oz. iii doses every hour. Met. F. Sol. Sodium salicylate in doses of two to c^j^ Teaspoonful every two hours, three grains every two hours to a child ^^^ ^^^.^.^^^ ^^ ^^^ ^^^^ j^ ^^i^^ j^ a year old has been recommended. Ir- . , , , Ti? rigation of the stomach and large bowel ^o assist in checking the bowels. If is of great service, and when the fever there is much blood in the stools, I add is high, ice water injections may be about M xxiv Flext. Ergot, to the first used or a graduated bath. Starch prescription. (ounce ii) and laudanum (mii to iii) ^^^ after 'care of these patients is, in injections, if retained are soothing and , . . . ^ , beneficial. The combination of bismuth ^y humble opinion a very important and Dover's powder will also be found factor. We must take into considera- beneficial. tion the fact that these little folks are Hughes — delicate, tender and should not be held Pulv. Ipecacuanhea gr. i/i in the arms or on the lap. In fact, I Bismuth Subnit. gr. v-x believe that they are handled too much Cretae Prep. gr. iii ^ sympathetic mother and rela- Ms. Every two hours. ^ "^ ^ , , , . . Bichloride of mercury gr. 1/100 ev- ^ives. I recommend bathing frequently ery hour or two will free the evacuation to allay the fever and keep the body of blood and slime. Nuclein (Auld) gr. clean. I find that witch hazel is a very 1 every hour until the character of the good preparation to use on the body af- stools change is also of value. tej, bathing. The return to the normal My own method of handling these ^^^^^^ ^^ ^^^^^ ^^^ ^^^ .^^^ cases is about as follows: I stop all , ■, , . feeding from the breast or bottle and should not be discharged too soon. Keep substitute rice and barley water. I them under observation until you are feed one tablespoonful of rice water and sure that they are entirely well. 188 SOUTHERN MEDICINE AND SURGERY April, 1922. r> A o A T T»/f ^n, A T.^T wr^ ^^r^T^T^niwTi^T a The iTiethods used in clinical work to- BASAL METABOLIC DETERMINA- ^^^ ^^^j^^^e the heat production by TIONS* measuring the amount of oxygen con- T> r> • 4. WIT ^^TT^ T>- 1. j tr sumcd, or the amount of carbon dioxide By Carrmgton Wilhams, M.D., Richmond, Va. , " ', -, , r ^ i- . -, the end-product of combustion excreted, That chemical reactions produce heat by a patient at rest and after absorp- is best illustrated by the combustion of tion of food is completed. The patient coal in our ordinary fires. The more is therefore tested in the morning be- complicated reactions in chemical labor- fore breakfast, and is allowed to rest in atories, and the most complex reactions bed for a short period before the test which produce activity in the human is begun, body, likewise produce heat. These determinations give us an ac- A locomotive working against the curate measure of the chemical activity traction of a heavy train would require or heat production going on in the in- a greater amount of heat production dividual. This result is compared to than one idle in the yard. So a man the normal standard as has been estab- working under high pressure requires lished, and is expressed in percentage and produces more heat than the same above or below this normal. A reading man at rest. To carry the comparison of plus or minus ten is considered nor- further, the amount of heat produced mal. by a locomotive would vary not only The mathematical problem is more or with the work being done, but with the less complicated because we have to fig- size of the locomotive and its state of ure on the age, height and weight, or repair. An idle engine with all the body surface of the patient. This is draughts open might easily produce the being made easier by tables of figures same amount of heat as one of the same calculated for the varying conditions, size pulling a train. It is also true of and can be reduced to slide rule manip- man. ulation. The process of chemical activity, by Boothby has shown by an enormous which heat is produced in man, is called series of tests that 95 per cent of the metabolism, and the amount of heat cases of increased metabolic rates are produced by man at rest, and in the due to increased secretions from the post absorptive stage, is called the "ba- thyroid gland. Clinically therefore, we sal metabolism." The rate or amount are justified in assuming thyroid hyper- of basal metabolism activity will of function where the metabolism is appre- course vary with the size of the indi- ciably above the normal limit, having vidual, sex, age, and certain pathologi- excluded of course febrile conditions, cal states. and a few disorders, particularly per- The process of oxidation going on in nicious anaemia, leukaemia, acromegaly, the body to produce heat has been rec- and diabetes. Boothby has also shown ognized for more than a century. It that subcutaneous injections of epine- has been only in recent years, however, phrin will increase the metabolic rate, that we have learned to measure it, and but he knows of no definite clinical syh- during the past ten years, there have drome in which the suprarenal glands been many advances in the accuracy cause an increased metabolism, and ease of the methods. We would expect a decreased rate in Lusk and DuBois, in New York, and cases of inanition, but in the cases with Benedict, in Boston, have been the pio- lowered rate, there is a thyroid defi- neers in simplifying the apparatus from ciency in a large majority of cases, the large direct calorimeter to the small especially in the obese, practical spirometer machine which is Clinically, we apply the results large- suitable for clinical use. ly to thyroid disorders. Exophthalmic Goiter — In the frank *Read before the Richmond Academy of case with tremor, tachycardia, and ex- Medicine and Surgery, Oct. 11, 1921. ophthalmos, we do not need the test April, 1922. SOUTHERN MEDICINE AND SURGERY 189 for diagnosis, but the extent of the in- increased, the dosage is too small ; on creased rate is a valuable adjunct in the other hand, if the dosage increases determining the severity of the condi- the rate, and the sj'mptoms fail to im- tion. In the preoperative treatment of prove, we must look elsewhere for the a case, a decline or a rise in the rate is trouble. an indication for or against operation, Adenoma of the Thyroid — The early and after operation, the drop is quite adenoma, like the adolescent goiter, will an accurate measure of the success of give a normal or subnormal reading, the procedure. So it is also in cases but it is now generally accepted, as first being treated medically, or by X-ray or proposed by Plummer, that in later life, radium. these adenomata may take on an in- In the doubtful exophthalmic, the test creased activity, resulting in hyperthy- is extremely helpful. Incipient tuber- roidism. These cases give an increased culosis, effort syndrome, and the so- metabolic rate early in the stage of called neurasthenia, can give a train of hyperfunction, and this gives us a val- symptoms and signs frequently almost uable indication for operative interfer- indistinguishable from hyperthyroid- ence. ism. The metabolic rate in these con- Hypothyroidism — The frank cretin ditions should be normal or below, while and victim of myxedema can be readily in the early hyperthyroid, it is appre- diagnosed without the metabolic rate ciably increased. determination, but the treatment to be Adolescent Goiter— We mean by this accurately administered, should be con- the symmetrical enlargement of the trolled by these tests. The mild hypo- thyroid gland seen most often in young thyroid, however, can only be safely women, due most probably to an effort diagnosed and treated by basal meta- on the part of the gland to compensate bolic determinations, for a lack of secretion. This is borne Summary out by the studies of Marine, in which he has shown that the size of the goiter We now have a simple machine of can be reduced, or its appearance pre- sufficient accuracy and ease of opera- vented by administration of the iodides, tion for determining the rate of basal These young women have varied nerv- metabolism. This rate must be com- ous and cardiac symptoms, and can be pared to the normal which is sufficient- easily mistaken for exophthalmic goit- ly standardized. er. Many of them have been operated ^he determination of this rate is o^ on in the past, and each such operation assistance in the differential diagnosis is a calamity, because the gland is mak- ^f g^rly hyperthyroidism. It is an in- ing an effort to increase the deficient dication for treatment, and a measure secretion, and the surgeon reduces it by ^f ^Yiq success or failure of any line of removal of part of the gland. These treatment, and may indicate the neces- patients need thyroid extract, or the gjty for change of treatment, such as iodides, as can be demonstrated by the supplementary X-ray after operation, basal metabolic determination, which is qj. removal of part of the gland after usually below normal. And here may X-ray failure. we say that we believe that every pa- j^ ^jjj indicate the futility of opera- tient to whom thyroid extract is bemg ^^^^^ ^^ adolescent goiters. It will aid administered over any considerable ^^ ^^^ diagnosis of hypothyroidism, and time, should be controlled by these tests, g^^trol the treatment when thyroid ex- because a condition of hyperthyroidism ^^^^^ -^ ^^^^^g administered, can be produced by an excess of the ^,^ ^^U^^^ ^^^^ ^^^^^ deter- drug, while an insufficient dose which ^.^^^.^^^^ ^^.^ now an indispensable aid IS not producing results, may lead the -^ ^^le diagnosis and treatment of all physician to abandon the appropriate disorders of the thyroid gland, treatment. If the metabolic rate is not 400 East Franklin St. 190 SOUTHERN MEDICINE AND SURGERY April, 1922. THE MENACE OF DRUG ADDIC- TION—SUGGESTIONS FOR ITS ERADICATION* By Louis E. Biscli, M.D., Ph.D., Asheville, N. C. To present a paper on the menace of drug addiction to a society of physi- cians would seem to be analogous to ''carrying coals to Newcastle." Yet, although all of us realize the scope, the difficulties, and the seriousness of this problem, there are few, if any, who would claim that North Carolina has solved this perplexing question and that it is meeting the situation adequately. To be sure, since the passage of the Harrison Narcotic Law in 1914, the Fed- eral Government through its Commis- sioner of Internal Revenue, has con- ducted a vigorous campaign against narcotic drugs, but it must be remem- bered that the law is primarily a reve- nue measure and that the Federal au- thorities never posed as doctors nor did the act attempt to supplant the physi- cians in the treatment of habitual us- ers. If, in controlling and restricting the amounts of narcotics that may be prescribed under the law, more serious attention was called to these pitiable unfortunates, and if perchance such propaganda has resulted in a more scientific handling of these cases, it cannot be denied that the problem in last analysis remains distinctly medical. Furthermore, although the Treasury Department had hoped to secure the assistance of the United States Public Health Service looking towards the in- stitutional care of addicts, no appropri- ation has been made by Congress for this purpose and so the burden for the care of drug cases really falls upo;j state and municipal authorities just as the indigent sick of a community are public charges.' North Carolina has no statistics by which to estimate the number of drug addicts within its territory. However, it is believed that there are over 1,000,- 000 ad'dicts in the country, although estimates have run as high as 4,000,- 000. This is taken from a report of a special committee of investigation ap- *Read before the Annual Session of the Medical Society of the State of North Car- olina, April 26, 1921, Pinehurst, N. C. pointed by the Secretary of the Treas- ury and published in June, 1919. In it we also find the following data: that the number of addicts under treatment by physicians registered in North Caro- Hna at the time of the report was 8,077 (which is probably an underdetermina- tion since it is based on an estimate of only 27 per cent of the physicians who replied to the circular questionnaire) ; that "the consumption of narcotic drugs in this country has steadily increased from the date of their introduction;" and that "about 90 per cent of the amount of these drugs entered for con- sumption is used for other than medi- cal purposes." We read also that "the predisposing causes of drug addiction in order of their frequency as stated in the reports of health officers are chronic diseases; prostitution, mental troubles, nervousness and neurasthenia. The ways in which the habit was acquired, stated in the order of their frequency, are as follows: Through physicians' prescriptions, use of drugs for chronic diseases, prohibition, association, use of patent medicines, prostitution, as a means of producing stimulation, and through curiosity." "The drugs used by addicts in order of their frequency, as shown in the re- plies to all forms of questionnaires sent out by the committee, are as follows: morphine, heroin, opium (all forms) and cocaine. Codeine, laudanum, and paregoric are reported as being used in about equal amounts, but to a lesser extent. In recent years the use of heroin has greatly increased, and in some communities it is at present used more extensively than any of the other drugs."' It is interesting to note here that heroin, which is usually used as a snuff and forms a habit very quickly, has practically no therapeutic value. And in considering the ways in which drug addiction develops we must not forget the enormous quantities of pat- ent medicines that are taken, often in- nocently, but which are exempted un- der Section 6 of the Harrison Act. Paregoric which, according to the United States Pharmacopoeia standard, contains a little less than two grains of opium to the fluid ounce, is perhaps the worst offender. It can be bought without prescription, as it is exempt within the law. There is no information at hand to controvert that what is true of the na- April, 1922. ORIGINAL COMMUNICATIONS tion also pertains to this State. Our Consolidated Statutes contain sections dealing with the sale, limitations on possession, and the filling of prescrip- tions referable to specific habit-form- ing drugs, yet these sections are prac- tically repetitions and interpretations of the Harrison regulation. It follows, therefore, that if the Federal act has not cured the evil, our ow^n legislation cannot have tended to better conditions. The State Hospitals at Morganton and Raleigh are supposed to take drug cases but we all know how overcrowded they are and that they cannot even take care of the psychotics that apply for admission. In addition to these tw'o in- stitutions there are about a half dozen private sanitariums that more or less specialize along these lines. Since the bed capacity of the latter is very lim- ited and since many addicts cannot af- ford to pay for institutional treatment, these latter hospitals cannot help much. The result is that the hospital facili- ties in North Carolina are totally in- adequate for caring for addict patients. In order to meet a similar situation in other places drug clinics have been established in the past with the intent of relieving the suffering of those clam- oring for treatment but in conformity with the law. Notable examples are the clinics of New York City and New Orleans. Both were failures. The clinic in New York was opened in April, 1919, by the Board of Health. It was closed in March, 1920. "Its fail- ure, and the lessons learned by its trial for eleven months, are well described by Dr. S. Dana Hubbard, in the Public Health Reports for March 26, 1920. "It was found that of the 7,400 drug addicts who attended the clinic for their narcotic, less than 2,000 were walling to go to a hospital for treatment, with ul- timate cure in sight. The officials of the department were convinced that it was not the proper procedure to give narcotic drugs to addicts for self -admin- istration. Some addicts sold the excess obtained at the clinic to other addicts or peddlers. There was fraud in ob- taining the drug. Friends of addicts became habitues through association with beneficiaries of the clinic. With very few^ exceptions, no cures were known to have been effected by means of the reduction system used. Ambu- latory treatment was found to be vicious in principle and in effect. There is no need of prolonging addiction by a con- tinued supply of narcotics.'" A similar clinic was opened in this State by the Durham-Orange County Medical Society on December 23, 1920. The purpose of the clinic was not to cure drug addicts, but only to take care of the incurable cases in these counties; It was closed after two months.* It may be added that although the Internal Revenue Department at first approved of such clinics so as to meet local emer- gencies, it later came to the same con- clusions as those given by the New York Board of Health. Since, then, North Carolina has no clinics and can not take care of its habitual drug users in hospitals the natural result must be that its addicts are in the great majority of cases be- ing treated from the medical practition- er's office and by the ambulatory reduc- tion method. Anyone who has studied the subject at all knows that when gradual reduction is employed without absolute control of the patient the pro- cedure is invariably ineff'ectual and is always doomed to failure. There are a number of treatments for drug addiction besides the gradual with- drawal method, the most eff'ective being the Lambert and the Hyoscine treat- ments. The Lambert system is one of drastic intestinal elimination together with the administration of belladonna and fluid extract of hyoscyamus in drop doses for about 60 hours. The Hyoscine procedure begins also with elimination, both skin and intestinal, for several days, followed by hypodermic injections of hyoscine hydrobromate for about 48 hours. Many modifications of these treatments have had their vogue and repeated injections of salt solution into the veins have also been employed. It matters little which type of treat- ment is employed so long as the patient is isolated and controlled in every par- ticular while the taking-off process is going on. In fact, it is not really a very difficult matter in most cases to carry a patient through to total absti- nence and it can often be brought about in a few weeks. The trouble is— and here lies the crux of the whole prob- lem— that he will almost invariably re- turn to the drug again. What must be thoroughly understood and most strongly emphasized is that the narcotic addict does not revert to his old habit willingly or willfully 192 SOUTHERN MEDICINE AND SURGERY April,:i922. through innate viciousness on his part, its proper treatment. The medical pro- He goes back again and again for no fession, as a profession, has not con- other reason than that he absolutely sidered narcotic addiction seriously, this cannot help himself. aloofness leading to error on the part One need not dwell here on the mark- of the public and to unmerited suffer- ed mental and physical deterioration, ing by the addicted. ' No constructive often disorganization, that always fol- national program has been presented, lows sooner or later in the wake of ad- repressive laws being the only national diction. Habit-forming drugs hold their achievement thus far, in this field. A victims in an inexorable grip of domi- more unscientifically handled class does nance that has no parallel anywhere, not exist." The mere withdrawal of the drug to We, as physicians, must recognize which they have become enslaved, pro- without prejudice or reservation that duces such unrelenting discomfort and drug addiction is not a crime but a dis- cravings, often of a distinctly painful ease. Certainly it is just as much a dis- organic nature, that the addict will lie, ease as is insanity. It was through the steal, commit depraved acts, and even efforts of enlightened physicians that murder in order to obtain a dosage that the inhuman and medieval handling of will relieve his anguish. Cocaine brings psychotics by society was abandoned in about a more rapid destruction of men- favor of our modern 'asylum; likewise tal powers and moral sense than does is it our duty to instruct the public, ed- the opiates. Heroin acts much like co- ucate officials, and afford the addict an caine. The Federal investigating com- opportunity to cure and rehabilitate mittee mentioned previously found that himself on a sound, scientific, rational the users of opium and morphine are basis. more apt to commit such crimes as lar- When the addict has been taken off ceny, burglary, vagrancy, forgery, as- his drug, the cure has only begun — the sault, and violations of the drug laws, first step towards permanency in physi- while cocaine and heroin users are more cal, mental, moral and social regenera- given to brutal and violent crimes. tion has alone been consummated. What Nothing is more fallacious than the the requirements of the narcotic suf- opinion held by so many — even some ferer urgently demand are prolonged physicians — that a narcotic addict can after-care treatment under skilled control his habit by an act of his own hands, removed from the old environ- will power. What the addict is not is a ment and associates that incite so free, untrammeled human agent with strongly to relapse, and an enforced, normal intellectual faculties that can controlled, re-educational regime includ- hold emotional strivings in check. What ing individual, analytical studies, psych- he is is a pitiful, despised, misunder- ological training, occupational and rec- stood creature that has to a greater or reational therapy, etc. In short, the pa- lesser degree lost his sense of moral and tient must be taught a new point of social responsibility, suffering often un- view, and given a new lease of life, told agonies of body and mind, and All this can best be accomplished in fighting often an intangible demon an institution specially designed for this whose ravages put the creations of purpose — preferably of the colony plan Dante's "Inferno" to shame. — to which the patient is legally com- As the Honorable Sara Graham-Mul- mitted by application or voluntarily, and hair said before the American Public until such time as the supervising med- Health Association in 1920, "Acting ical specialists in charge deem it proper upon the mistaken theory that he could, to discharge and return him to the com- if he would, the unfortunate ad- munity as cured, or place him upon diet has been arrested, thrown into probation for such periods as circum- jails all over the country, and compelled stances may warrant, to suffer it out. The ignorance of of- If we are to make any real headway ficials is what might be expected, as in removing drug addiction in North neither they nor the general public Carolina it would seem that resolute, have been educated on the subject of concerted, and drastic action is neces- addiction. There has been so effective- sary. Every addict is an actual or po- ly-carried-out concerted effort by public tential menace to himself and to his health officials to enlighten the public fellows and the public health and safety as to the nature of drug addiction and is endangered if he remains a free, un- April, 1922. ORIGINAL COMMUNICATIONS 193 controlled, unrecognized, uncured mem- be established) whether the addict about ber of society. If health boards are em- to be treated has applied for similar powered to demand registration and iso- treatment elsewhere within the State lation in cases of contagion and set a finger print system being instituted aside laws with impunity in times of for purposes of identification, if neces- emergency, is there any reason why sary. similar powers should not be conferred Ninth, that a clause be added to the upon them to remedy this crying evil Public Health Law declaring the habit- which saps the very vitals of our social ual use of cocaine, opium, or its deriva- structure? tives to be dangerous to the public First of all, we must not shirk our health and safety and that magistrates duty as physicians m aiding State and and local health officers be empowered Federal officials, not only morally but to commit an habitual user, upon his actually, m enforcing the present laws application, to a proper institution, in their endeavors to suppress the ne- Tenth, that if an addict apply for re- farious traffic m narcotics Auction or cure for the third time to Secondly we should institute a State- physician, that said physician in wide educational campaign under the conjunction with a colleague, be permit- auspices of our State Board of Health ted to make application for the com- in order to instruct the lay public con- fitment of said patient through proper cerning the problem and to warn them jg i channels— the procedure being an- of the dangers of proprietary medicines, ^logous to that emploved in cases of Third, we should inaugurate some Junacv sort of canvass bv means of which the -cii "^ 4.u i-i, ^ • j- j. ^ i ^ Board of Health may come into posses- , Eleventh, that immediate steps be ta- sion of statistical data concerning the ken to invoke the State Legislature to extent and character of narcotic addic- authorize the erection of a hospital de- tJQ„ voted to the treatment and after-care Fourth, we should do everything in ^^ ^.^^^^* ^^^^^^-f^'^ hospital only to our power to discourage and, if possi- receive committed patients, ble, legislate out of existence, the treat- Gentlemen, the writer realizes that ment of addicts by the ambulatory re- what he has suggested as a remedy for duction method. the eradication of the menace of drug Fifth, we should take proper steps addiction is ambitious and comprehen- that onlv physicians who are reputable ^^^^^^e. However, nothing short of such, in everv particular mav be able to se- or similar, vigorous measures will cure licenses to prescribe or dispense strike at the roots of the problem. This narcotics, and in this regard special P^Per has not been presented as a final care should be exercised that no phy- o^ even a profound treatise. It is based sicians obtain such licenses who are "P"" the writer's own experience with themselves addicts drug cases as a neuropsychiatrist and Sixth, our statutes- should be so "Pon his study of the experience and amended that no proprietary medicines, opinions of others. It is hoped, how- no matter how little their percentage ever, that enough of these suggestions of habit-forming drugs, can be purchas- may be sufficiently stimulating to m- ed except upon the prescription of prop- augurate some definite stand or activity erlv registered phvsicians under the on the part of this society, lookmg to- Harrison law. " wards practical reform. Seventh, that it be made compulsory References for all phvsicians of the State to regis- ter and give certain descriptive data l- "Enforcement of the Hamson Narcotic concerning all addicts under treatment Law"— Bulletin issued by the Treasury De- by them of whatever sort or emergency partment to its Collectors of Internal Reve- — the term addicts not to include pa- "ue, etc., 1919. tients, who are suffering from chronic, 2. "Traffic in Narcotic Drags"-Report of wasting diseases, and who are receiving Special Committee of Investigation appointed narcotics under the personal direction of March 25, 1918, by the Secretary of the Treas- physicians. ^^'y^ published June, 1919. Eighth.^'that physicians who attempt 3. "Narcotic Drugs and Crime"-Report of to cure addicts be required to inform Committee (G) of the American Institute of themselves from a central bureau (to Criminal Law and Criminology, Sept., 1920. 194 SOUTHERN MEDICINE AND SURGERY April, 192 2 PROLAPSE OF THE UTERUS* By Frank D. Worthington, M.D., Charlotte, N. C. While complete prolapse of the uterus is rare the various stages of relaxation of the outlet and descensus and malposi- tions of the fundus are common. As long as women continue to bear children this condition is destined to be but it is within our power somewhat to prevent it and decidedly in our power to cure it. The first move in prevention is in the hands of the obstetrician. By imme- diate repair of child-birth lacerations he may approximate the perineal struc- tures so that the loss of support is only that due to stretching and deep separa- tion of fibers. How frequently it hap- pens, however, that the amateur obste- trician approximates only the surface mucous memebrane and leaves the un- derlying muscle structure widely sepa- rated. The result is cosmetically good until the perineum is called upon to support when all virtue of the repair is conspicuous by its absence. Deep su- ture of the muscles is absolutely nec- essary if the repair is to be of any last- ing functional benefit. A small percentage of perineal repairs break down and even those that hold cannot restore a support comparable to that of the nullipara so that inevitably malpositions will occur. These malpo- sitions grow progressively worse and lead to innumerable symptoms. They may finally lead to a complete prolapse and since the operations in the inter- mediate stages are attended with such unusually good results with the mini- mum of risk they are strongly advised. If I may be permitted to digress slightly we are all familiar with the frequency of distressing bladder symp- toms when a moderate or pronounced descensus is present and we are inclined to fall into two pitfalls. First, we may overlook the presence of pathological conditions in the bladder, kidney or ure- *Read before the Mecklenburg County Med- ical Society Charlotte, N. C, Jan. 24, 1922. ters which are not at all due to the cystocele present and it is frequently the part of wisdom to cystoscope these patients and either reassure ourselves that the cystocele is the cause of the symptoms or eliminate any other causes. Secondly, when the operation is done the repair of the cystocele is in reality simply the excision of redundant mucous membrane. It is essential to support the bladder by plicating the fascia and frequently to dissect the bladder free from the cervix, otherwise the cystocele recurs. So much for efforts to prevention of complete prolapse. With the condition present we may meet it in a number of ways. Usually the patient is an elderly woman past the child-bearing age. This simplifies our difficulties un- less she is too feeble to stand any kind of operation. In such cases a large ring pessary with possibly a rubber sponge pessary in addition is the best means of preventing prolapsus but these measures are not very satisfactory. If the patient is still menstruating there are several means of curing. (1) Repair below and suspension ab- dominally. The objection to this is that unless a ventral fixation is done the condition is liable to recur. Ventral fix- ations are not only non-surgical but ofi'er a splendid opportunity for intesti- nal obstruction and in addition are fre- quently quite painful. (2) Repair below, followed by supra- vaginal hysterectomy and a high sus- pension of the cervical stump. This is a very satisfactory operation and in the presence of any abnormalities on the fundus such as tumors or any pathology in the adnexae is the operation of choice. (3) The interposition operation known in this country by the name of Watkins and abroad as the Wertheim Fixation. It is especially this operation that I wish to emphasize since in my opinion it is decidedly the operation of choice when the above mentioned pa- thological conditions of the fundus or adnexae are not present and in practice it may be performed in two-thirds of the cases. April, 1922. ORIGINAL COMMUNICATIONS For the benefit of those who may not be familiar with the technique I will briefly review it. With strong traction made on the cer- vix a longitudinal incision is made through the mucosa on the anterior vaginal wall from just below the ure- thral orifice to the cervix. This incision is then carried around the cervix and a high amputation of the latter done. Flaps on the anterior vaginal wall are then dissected back laterally exposing the bladder. The bladder near the cer- vix is then picked up and dissected free from its attachment to the uterus. This dissection is carried well out to the sides and the peritoneum where it reflects from fundus to bladder exposed. The peritoneum is opened, the fundus grasped and pulled forward. Traction sutures are then passed through the mucosa and vesico-vaginal fascia on one side, through the fundus and out through the vesico-vaginal fascia and mucosa on the opposite side. These sutures are not tied. The peritoneum is then closed around the fundus. The bladder is pushed back behind the fun- dus, the redundant musoca and fascia are excised and they are closed in lay- ers in the midline. The traction sutures mentioned above are then tied as the tension on the cervix is released. The fundus is thus held as a buttress be- tween the bladder and the anterior va- ginal wall. A rather tight perineal re- pair is then done. The advantages of this operation are as follows: (1) It holds. Tilting the fundus for- ward puts its ligaments on a stretch and changes its axis of gravity so that it does not tend to push down into the vagina. (2) It cures the cystocele. This is the difficult proposition in other opera- tions and the one that causes the most trouble. (3) By the high amputation of the cervix which is always hypertrophied and frequently lacerated in these cases a very considerable weight is removed from the uterus. (4) It is much less trying in every way on the patient who is frequently a poor operative risk. It is the experi- ence of every surgeon that perineal operations are not accompanied by shock, the amount of anesthesia needed is not so much as for abdominal cases and the likelihood of complications is smaller. To these reasons may be add- ed that the patient suffers compara- tively little pain, has no distention and may sooner be placed on normal diet, etc. The occurrence of temporary urinary retention is common and the aggrava- tion of a chronic cystitis not rare but these occur no less frequently in the other types of operation. (5) Finally, because of its relative safety it offers a cure to a larger num- ber than any other operation. OUR BEST ONLY By Henry Norris, M.D., F.A.C.S. Surgeon to Rutherford Hospital, Rutherfordton, N. C. Consulting Surgeon to State Hospital, Morganton, N. C. In almost everyone there is an ele- ment of the mysterious and a curious interest in the unknown and little un- derstood things of life; with a healthy body and a normal mind, fairly well trained, leanings or impulses towards the occult may be resisted but when disease makes inroads upon vitality, the mental outlook necessarily changes, and the individual naturally reaches out for help, usually to a physician of the reg- ular school first. Perhaps several will be tried for the desire to live and be well is the strongest impulse which dominates our lives. Failing to secure relief, the sufferer continually has his hopes raised by reports of cases ap- narently similar to his own which have been cured by Dr. Blank, and so he goes the rounds of the regulars until he descends to the irregulars, the steps be- tween being easily taken. It is useless l^G SOUTHERN MEDICINE AND SURGERY April, 1922. to rave against the various praetors ousy with its train of resultant evils; and healers and to do so shows a lack there is plenty of work for all of us of self analysis. The remedy lies in and none of the really great men of the hands of the medical profession, it our profession have failed to realize is we who make possible their living that by helping the other fellow, they by our failures. From the fashionable have helped themselves. Thoroughness, yogis who ^each the unoccupied rich each day, in all our professional rela- elemental physiology, consisting princi- tions and acts, is the first step towards pally of deep breathing and exercises better work, more care in examinations, which tend to correct ptoses and over- more willingness and desire for help in come habitual constipation, to the igno- difficult cases, and a conscience work- rant healers who do not possess even ing overtime; that is what we should average intelligence, all wax fat not strive for. Years ago I overheard in alone upon the credulity of their vie- a train a young surgeon of promise tims, but aided and abetted often by damning with faint praise his colleagues our carelessness. I regret that the gen- in a neighboring city, that little spirit eral diagnostician has almost passed ; in showed up the man and his success has the larger cities group medicine has not been great. There is always some- taken his place and in most instances one better than we are ourselves: we the public is better off; it is in the less grow stronger by seeking strength and densely settled parts of the country we belittle ourselves by trying to cover that countless individuals are in need up our weaknesses. United with a com- of intelligent guidances. State medical mon interest, unselfish with an unself- service of the highest standard blocked ishness perhaps not equalled in any off in areas with adequately equipped other profession, we can do much to- standardized hospitals ; staffed by men wards conserving health and happiness given a salary high enough to. com- and protect the people in our charge mand the best, is what we should all from those who prey upon their bodily look forward to. From these centers weaknesses, but we, ourselves, must be preventive medicine could be taught, the above reproach, only our best will do foundation for which should be given and never must our judgment or inter- in the public schools as part of the cur- est be in the very least degree influ- riculum. Medicine must not be com- enced by that necessary evil — money, mecialized, without the human element the highest success cannot be obtained. Many of us will not live to see and reap the benefits of such an ideal solu- tion, but all of us can do our little now towards it by developing our consci- ences. Each and every one of us can sow seeds steadily which will grow and SPECIAL TRAIN FOR A. M. A. MEETING develop perhaps beyond our present un- derstanding by giving always our- best only. All of us can look back and re- Special will leave Richmond at 7:00 P. M. member cases which we have not done Monday, May 22nd, arrivins St. Louis 9:00 our full duties towards, but usually be- cause of carelessness, if the truth be P- ^- Tuesday. Twenty-five per cent reduc- sifted out. If I were asked what was tion in fare. Address J. L. Stines, Southeast- the most valuable asset for any young ^^^ pa^sencer Agent, C. & O. Ry. Co., Rich- man starting out in medicine to pos- sess, I would say "fearless honesty," "^«"d, for reservations, and this I mean in its broadest sense. Like all other human beings, doctors have their weaknesses and faults and one of the most to be dreaded is jeal- April, 1922. EDITORIAL 197 SOUTHERN MEDICINE AND SURGERY the study of medicine to gain admission Published Monthly by the to the schools. There are a very large number of students in the pre-medical Charlotte Medical Journal Company courses in our colleges, and many of M. L. TOWNSEND, M. D. | , them will be refused admission. /. c. MONTGO.nERY, M. D. \ ^''"''" r^^^ problem does not involve merely CHARLOTTE. N. c. the Continued existence of the two-year medical school, but the larger problem "Read not to contradict and confute, nor to ^f ^^ adequate supply of physicians. believe and take for granted, nor to find talk There are (3nly two states, South Caro- and discourse, but to weigh and consider."— Una and North Dakota, with so few phy- Francis Bacon. sicians to the population as North Car- ^^^^^^^^^^'^!^^^^^^^^^^^!^^^^^^^^^^^^ olina. The ratio for the country as a whole is given as one to seven hundred Higher Medical Education in North ^nd twenty. In North Carolina the ratio Carolina jg Q^e to eleven hundred. There are The most vitally important questions many communities in North Carolina before the medical profession of North without medical service, and there is Carolina today is the crying need for a much medical work that is not being thoroughly equipped and efficient fin- done. The increase in the number of ishing school for students of medicine, physicians is not keeping pace with the I said "before the medical profession" growing in population. There is not but this critical need is not a question only an inadequate supply of physicians which concerns the physicians only, it in the State, but under present condi- is an equally vital question which con- tions the outlook is very insecure. We cerns every man, woman and child in have depended entirely upon schools lo- the great commonwealth and also to cated in the large cities for a very es- her millions of yet unborn. sential part of the training of our phy- Dr. Isaac M. Manning, Dean of the sicians, and it is becoming evident that Medical Department of the Universitv ^ve cannot depend on them very much of North Carolina, in his annual report, longer. We must plan for the trammg which was incorporated in 'The Presi- of our own doctors, dent's Annual Report" to the Trustees, The fact that there is no very large has said in part as follows: city in the State is not an insuperable "The time has now arrived when we difficulty. It is entirely possible to con- should give serious consideration to the duct a thoroughly creditable clinical matter of establishing a four-year school in a town of less than twenty school and offering the complete medi- thousand people, as is being done at cal course. The efforts to raise the Ann Arbor by the University of Michi- standards of medical education by the gan, and as will be done at Madison by American Medical Association and other the University of Wisconsin. Given a national organizations have reduced the hospital with two hundred beds, prop- number of medical schools from one erly equiped and supported and manned hundred and sixty-two to ninety-six and by a qualified teaching staff, it is entire- the number of graduates from fifty-five ly possible to conduct an acceptable hundred to three thousand. The sur- clinical school in any one of several viving schools have found it necessary towns in North Carolina. People in to limit the enrollment in all classes to need of medical advice will go wherever such a degree that it is becoming in- it may be had. The cost of maintaining creasingly difficult not only to transfer a clinical school, if conducted on modern students who have completed the first and approved lines, will be no greater two years of the medical course to de- in North Carolina than in any other sirable clinical schools, but it is equally state or city. The cost, however, offers 198 SOUTHERN MEDICINE AND SURGERY April, 1922. the most serious difficulty in the solu- for none other has more right or more tion of the problem." qualifications for being a leader. But We have said before (page 584, Nov., how about the provision for supplying 1921) that there are only two states in this prosperous and growing people this country where doctors are so scarce with an adequate supply of doctors ? as in North Carolina, and no provision North Carolina is no longer a poverty is made within the state for completely ridden strip of country, but is develop- training more, while the depletion of ing— indeed has already developed into the state's present supply is going on a mighty empire, willing and able to at the rate of 50 each year and her undertake and do the things which population increasing at the rate of 35,- seem necessary and advisable for a 000 each year. This means that an al- great state to do. We do not know how ready very lamentable situation is far the paternalistic attitude of a state growing worse each year at the rate of toward its citizens should extend, but 100 doctors annually. It means, abso- we have become so accustomed to the lutely, that 150 doctors must be trained government providing so many other each year, finished training, to replace things that we should not be surprised the annual death rate, care for the at ourselves for demanding that our state's increasing population and catch own state government take some part, up with her present shortage, so that at least, in making provision for ade- the citizenship of the state may secure Q^ate care of the sick citizens of the the help they need, for health, happi- state by seeing to it that competent ness and prosperity. doctors in sufficient numbers are scat- Are we going to fold our hands, is ^^red throughout the state. She should the medical profession, on whom the ^^oPt P^oper measures for making doc- right to practice medicine, has auto- ^ors from start to finish of her own maticallv placed the responsibility of ^0""^ "^^n. There is no doubt of the being the leaders in such matters— go- financial ability of the state to do this, ing to let the people of North Carolina ^nd there is no doubt, likewise, of the suffer for medical help while her tax- economic wisdom of the state providing, payers are handing out from her great by training her own sons, physicians of wealth enormous sums for all other '^^^ own. forms of civic and physical improve- There are three fundamental things ments. Indeed what will it profit a essential to sound medical education: state to gain the whole world and lose physical equipment, competent teachers its own health? and clinical material. North Carolina A few days ago Mr. Thomas L. Far- has the wealth, she has, or can get, the rar, vice-president of the Bankers' Ser- capable teachers and she has the clinical vice Corporation of New York, was in material. She has all of these in lavish the state and is quoted as saying, "Not abundance. She may not have any so many years ago North Carolina was large center of population but the whole looked on as one of the backward states state is a center of population and the in the Union. Now she is one of the necessary 200 or 300 bed hospital for most progressive." "Few other states," clinical material would always be filled he declared, "are doing as much public to overflowing, and a long waiting list work. No other state in the South and would be constantly clammoring for few in the North are building as many more beds. good roads The people here have more .p^^ ^^^^ f^^ ^ ^^^-^^^^ ^^^-^^^ ^^^_ faith in the future of the state than ^^^.^^ .^ ^^^ ^^^^^ ^^^^^^ ^^ exagger- they have in many other sections. , , ,. ^ .,-,•. • , • i ^i .,,,..„ ^ >T ^, ^ ated, the feasibility is obvious, and the And this is all very true. North Car- ,, .„ , ^ , . -, • olina is coming into her own among the "^^^^^^^ ^^" ^e powerful m producing most progressive and prosperous of her health, wealth and happiness for the sisters. This is just as it should be, present, and all future generations. April, 1922. EDITORIAL 199 Gynecology and Obstetrics Robert E. Seibels, M. D., Dept. Editor The Indications for the Interruption of Pregnancy If the pregnancy be terminated be- fore the child is viable, it is called the induction of abortion; after viability has presumably been established, we denominate it induction of premature labor. In general, we may say that an abor- tion is justified when a continuation of the pregnancy would seriously affect the life or the future health of the mother. When, by interference, we believe we may materially lessen the danger to the life and health of the mother or child, we may say the induction of premature labor is justifiable. We may class as absolute indications : 1. Active tuberculosis with hemor- rhages. 2. Acute, increasing toxemia. 3. Cardiac decompensation, not yield- ing promptly to treatment. 4. Accidental hemorrhage — including placenta previa. 5. Cancer of the cervix. The relative indications are many and some idea of the variety of opinion may be illustrated by the following tables : Von Jaschke' enumerates the cases he interrupted and those in which it was considered and refused, totalling 663 cases. Inter. Con. rupted. tinued. Tuberculosis 67 26 Heart Disease 17 9 Pronounced Anaemia 27 25 Nephritis 7 6 Pyielitis 32 31 Mental and Nervous 12 8 General Lowered Vitality 12 8 Varicose Veins 2 2 Hemorrhage I49 109 Contracted Pelvis 2 1 Osteomalacia 2 1 Thyrotoxemia 2 2 Tumors H 10 Abscess of the Lung 1 0 Intestinal Obstruction 1 0 Obtsinate constipation. Diastasis of the Recti, Exudate in Pelvis, Retroflexed Uterus, Gall Stones, Prolapsus Uteri, of each equal numbers interrupted and continued. The following are the indications in our cases; where interference was not done the case is not included: Acute Toxemia 7 Nephritis with Hypertension 6 Tuberculous Kidney 1 Pulmonary Tuberculosis with Hemorrhage, 1 Double Pyelitis 2 Placenta Previa 2 Deformed Pelvis 1 Decompensated Heart 1 Mental (Melancholia) 1 Diastasis of the Recti 1 Postmaturity with Justominor Pelvis 1 Death of the Fetus l Accidental Hemorrhage 1 It is not our purpose to discuss the indications we have given as "absolute" as they seem conservative enough to meet with approval. There are certain aspects of relative indications that may bear closer examination. 1. Tuberculosis. The most favorable type of tubercular infection is the fibroid phthisis, the most unfavorable is the laryngeal type. The paturient who be- comes tuberculous, if she is in good gen- eral health and has good surroundings, may do well in spite of her infection. On the other hand, tubercular women who become pregnant, usually do badly during the pregnancy'. Hussy' believes that it is the delivery that is the most serious factor with these cases, as the bacilli seem to be scattered widely at this time; this observation leads to the thought that in those cases in which the pregnancy is continued to term the delivery should be hurried and accom- plished in the minimum time compati- ble with safety. 2. Heart Disease. When cardiac dis- ease is discovered in a pregnant woman a question for nice judgment is present- ed. Mitral stenosis is generally accept- ed as almost an absolute indication for interference. Organic disease that shows signs of decompensation is bet- ter off without the strain of labor. 200 SOUTHERN MEDICINE A^ J SURGERY April, 1922. Mackenzie', in his exhaustive mono- with the chorea, they increase the grav- graph, brings out the three points to be ity of the prognosis, considered in mitral disease: (1) the In the face of the above comphca- response to effort; (2) the size of the tions, when interruption is decided on, heart; (3) and the rhythm. In aortic one should further consider a steriliza- disease, pregnancy may be permitted in tion. It hardly seems that the full duty a young woman, if there is no Corrigan has been done when the emergency is pulse, if the heart is only slightly en- met and the patient allowed to go on larged and if the response to effort is as a potential subject for another preg- good. In irregularities of rhythm, we nancy. If it is clear that no pregnancy have to consider either extra systoles or can be safely carried on, we advise that fibrillation. He found extra systoles in the abdomen be opened, a hysterotomy 50 per cent of normal women and where be done, and the tubes carefully cut it is the only sign, it may be disre- and their ends buried. This, when garded. In his experience pregnancy so menstruation is desired to continue : in weakens the fibrillating heart that he an older woman, hysterectomy should believes the patient with fibrillation be performed. All these procedures can should be advised never to become preg- be done under local anesthesia, nant. If pregnancy should take place, 7. Abdominal Operations. It was for- digitalis should be given in full dosage merly taught that when the necessity and labor induced if grave symptoms for an abdominal operation arose in a set in, parturient, abortion or premature labor 3. Nephritis, There is no statute of was inevitable and had best be induced, limitations on the toxemias of preg- This is no longer tenable, Grosse" has nancy. Even after protracted freedom collected the literature on double ooph- from hypertension and albumenuria, orectomy and cites 53 cases, in which one must face three outstanding haz- abortion occurred in only 13.7 per cent ; ards in allowing a chronic nephritic to it was more frequent the earlier in ges- go on — irreparable damage to kidney tation it was done. Myomectomy was and heart, prematurity, and eclampsia', performed by Farmer' in a three months 4, Pyelitis, Many women develop it primipara who went on to term. Even during pregnancy, go to term, are de- acute appendicitis and intestinal ob- livered and the pyelitis clears up. There struction have been successfully oper- are those, however, in whom it is far ated without interruption. An incar- more serious, and in spite of scrupulous cerated, retroflexed uterus, formerly care to maintain renal drainage, a pye- considered as an unquestionable signal lonephritis is set up and one or both for interference, is now successfully kidneys are seriously and permanently treated by laparotomy and suspension: damaged. No one symptom nor sign this method has the double advantage can be relied upon, it is here that the of giving a living child and of being assistance of a competent urologist is much safer for the mother. of the first importance. We have endeavored to show that 5, Mental and Nervous Diseases, with the exception of those indications Multiple sclerosis and myelitis seem to classed as absolute, there is wide lati- be unfavorably affected. Acute mania tude for good judgment to be exercised and melancholia, as puerperal psychosis, when interruption of pregnancy is con- are sometimes seen and such a history sidered. It is easy to be influenced and urges interruption. Epilepsy is not un- to be led astray, by economic and socio- favorably affected: we have one case logic arguments when more or less pa- under observation in the eighth month, thology is associated. And, if the lit- and she has been entirely unaffected by erature be searched, precedent may be the pregnancy. found for many interruptions not based 6. Chorea is prone to recur at this on sound judgment. Nowhere in pa- time and if it does, is apt to be quite thological states must the individual be severe. If psychic disturbances occur considered rather than the disease, to April, 1922. EDITORIAL 201 a greater extent, than in these cases. gery. Gynecology and Obstetrics, are so Finally, we must keep in mind that good we are reproducing them verbatim interference with the progress of preg- in this issue of Southern Medicine and nancy is not without danger — imme- Surgery. diate and deferred. In the urgent case we accept the lesser evil and interfere Htlmholz, H. F.: Modes of Infection in because the danger from it is not so Pyelitis — Am. J. Dis. Child., 1921, great as from the pregnancy. But sep- 606. sis is always with us and even though Since identical symptoms may be we escape the immediate storm of puer- produced by cortical abscess of the kid- peral sepsis, we may have to weather ney and infection of ureter, pelvis or a long period of pelvic ill-health. bladder, urine examinations are of little Bibliography value in localizing a lesion of the gen- 1. Von Jaschke: Monatschrift f. Geburt- ito-urinary tract. No large series of shulfe, 1920, IV, No. 51, 232. cases of pyelitis has been studied except 2. Davis: Progressive Medicine, 1920, Vol. by means of bladder cultures, and this III' 195. procedure determines simply that the 3. Hussy. Quoted by Davis. Ibid. organism obtained came from some 4. MacKenzie: Heart Disease and Preg- point in the genito-urinary tract. By nancy, Am. .J. Ob. and Gyn. (Abst.), Vol. 12, means of ureteral catheterization, the ^0- 6. location of a lesion higher up in the 5. Gibson: Surg., Gynec. and Obs., XXXII, urinary tract may be determined. This No. 6, 568. helps little in the determination of the 6. Grosse: Revue Franc, de gynecologie et mode of infection, but it demonstrates d'obstetrique, Nov., 1919, No. 14. the numerical incidence of infections of 7. Farmer: New Orleans Med. and Surg, the bladder and kidney. Jour., March, 1920. The number of necropsies in cases of The Medical Building. pyelitis is relatively small, and no sat- isfactory bacteriological study has been *Read at a meeting of the Columbia (Rich- made in any of them. Only instances land County) Medical Society, .lanuary. 1922. jn which necropsy is done very SOOn after death may be considered in the bacteriological investigation as the ba- Urology A. J. Crowell. M. D.. Dept. Editor cillus coli rapidly penetrates the organs after death. The pathologic report is negative in so many cases of pyelitis NOTE.— The Editor of this depart- that every effort should be made to ment wishes to correct an error appear- obtain all possible bacteriological evi- ing in the March issue. The second par- dence of the site of the lesion. Cultures agraph of second column should read: Irom the bladder, ureters, and kidneys "Our own experience with a modifica- will give an idea of the uppermost point tion of Young's perineal prostatectomy of involvement of the urinary tract. By for two vears leads us to believe that this means, a comparative localization the functional results following the re- may be made which it is impossible to moval of the gland en masse are better make during hfe. than by Young's original operation." The only conclusions of value to be drawn from postmortem examinations The abstract of J. H. Jackson, Jr., of of cases of pyelitis are those drawn H. E. Helmholz's paper, "Modes of In- from instances in which examination fection in Pyelitis." Am. J. Dis. Child., was made very shortly after death, 192], XXII, 606, and the one by C. D. since it is well known that the mucous Holmes of H. L. Kretschmer's paper on membrane of the pelvis is rapidly ma- "The Treatment of Pyelitis," Surg., cerated by the urine. The pathologic Gynec. and Obst., 1921, XXXIII, 632, findings of Thiemich, abscesses of the abstracted in the April number of Sur- renal cortex unassociated with lesions 202 SOUTHERN MEDICINE AND SURGERY April, 1922. of the bladder or pelvis, are probably gans which might have been factors due to the coccus group of organisms, predisposing to the occurrence of kid- and not to bacillus coli. In spite of the ney infections, relapses, or failure of large amount of infectious material that treatment. Thirty per cent of the pa- must have passed through the pelvis, tients had constipation and a small no involvement of the pelvic mucous number had haemorrhoids, fissures, fis- membrane was found. tulae, etc. Frequently the clearing up In cases of renal involvement defi- of infections of the prostate and semi- nitely secondary to lesions of the lower nal vesicles was associated with the urinary tract there is usually such cure of the pyelitis, marked destruction of tissue that the Renal infections may occur at any histologic picture is of practically no age but are most common in adults, 25.5 value as an indication of the mode of per cent occurring between the thirty- infection. In the majority of such cases first and fortieth years of age. The there is some condition damming the author believes it not improbable that flow of the urine. many cases of cystitis in infancy and It has been shown that renal infec- childhood are in reality cases of pyelitis, tion by the haematogenous route results Of the patients whose cases are re- in cortical lesions, while an inflamma- viewed, 39 per cent were males and 61 tory condition in the pelvis tends to lo- per cent were females. The bacterio- calize in the papilla. At the present logical examination showed colon bacilli time this is tho only feature which in 132 cases, staphylococci in twenty- makes possible a histologic differentia- eight, streptococci in one, colon bacilli tion between haematogenous and as- and staphylococci in ten, and staphy- cending pyelitis. lococci and streptococci in one. The Regarding the direct passage of or- findings in twenty-seven are not given, ganisms from the intestinal canal to Both kidneys were infected in ninety- the kidney by way of the lymphatics nine cases, the right kidney alone in the author states that not sufficient thirty-two, and the left kidney alone in evidence has been brought forward to seventeen. In twenty-one cases the warrant a discussion at this time. In bladder and both kidneys showed pus. view of the manner in which the lym- Qf ^he 177 cases in which more or phatic system develops, there is a pos- iggg accurate cystoscopic data were ob- sibility that m some cases a direct con- tained, 128 showed pathologic changes ; nection persists. 75 pgj. ^g^^ showed bladder changes G. H. JACKSON, JR., M.D. which varied in intensity from a slight amount of hyperaemia around the in- Kretsehmer, H. L.: The Treatment of Vernal urethral orifice to a generalized Pyelitis— Surg., Gynec. and Obst., cystitis. Pyelography was not carried 19^.1, XXXIII, 632. Q^j- ^g ^ routine procedure, but when This article is based on a study of pyeiograms were made they showed the 200 cases of pyelitis or pyelonephritis, ^g^al picture of infection. Lesions of a surgical natur-^ ^^/^,^^: Bladder distress was by far the most eluded These cases may be divided ^^^^^^ complaint. There was fre- mto the following clmical groups: (1) .^ ^^^ ^^^ ^^^^ ^^ ^^^ ^^^^ the pyelitis of infancy and childhood; ^^^^. .^ ^rj ^ ^^^, ^^^^ .^^^^ ^^.^^_ (2) the pyehtis of pregnancy (3) the ^.^^ .^ 3^5 ^^^^. turbidity of urine pyelitis of matrimony; (4) pyelitis fol- .^ 3^5 ^^^^. ^lood in the urine, lowing surgical operations; and (5) sim- ^^^^jj ^^ nioderate degree, in 24 per pie pyelitis. It is beheved that m the ^^^ -^ g ^^^^. .^^^^^._ pyeitis of matrimony, or defloration ^^^^^ .^ 5 ^^^ difficulty in 9.5 pyelitis, the colon bacilli gain entrance , .„ . ^^ through the tears in the hymen. P^i' cent; chills in 23 per cent; and a A careful search made in every case definite history of fever in 37.5 per cent, for the presence of lesions of other or- The patients with pyelitis of pregnancy April, 1922. EDITORIAL 203 appeared to be more acutely ill than in as satisfactory as before. Internal treat- the others. ment consisted of the use of alkalies, While the diagnosis of infection of acids, and urotropine. The routine man- the renal pelvis is not very difficult, agement was instituted with the admin- being based on the examination of di- istration of one teaspoonful of sodium vided specin-.ens of urine, colon bacillus bicarbonate in water three times a day, pyelitis ha3 often been mistaken for a enough to render the urine distinctly number of diseases. Stricture of the alkaline. Patients unable to take the sodium bicarbonate were given citrate of potash or citrate of soda. When the urine had become alkaline, 10 gr. of urotropine were given three times a day until the urine became distinctly ureter, large hydronephrosis, and renal tumor can be differentiated by the py- elcgram. Diligent search for the tuber- cle bacillus in association with the colon bacillus must be made. Repeated guinea pig inoculations often prevent an incor- acid. In the acute cases of pyelitis the rect diagnosis. internal treatment had a certain value. In 44.5 per cent of the cases there but as some of the patients with this was a history of some .sort of surgical type of infection get well without medi- operation. Such patients fall into the cation the value of these drugs remains following four groups: questionable. Group 1. Those who were operated In the author's opinion pelvic lavage on because of urinary symptoms, but is the most efficient method of treat- were not relieved by the operation, the ment. At times, even after a single inference being that they were operated ureteral catheterization for diagnostic on with insufficient study of the case. purposes, the pyuria and infection clear Group 2. Those who exhibited uri- up. Various drugs have been used for nary symptoms for the first time after pelvic lavage; Koll has obtained grati- some surgical procedure. In the pres- fying results with aluminum acetate, ence of insufficient data it is within the Mercurochrome has been suggested and bounds of probability that the so-called the organic silver preparations are in pyelitis (post-operative) may have been wide favor. In the series of cases re- an exacerbation of a latent pyelitis, ported, silver nitrate alone was used Some of the cases in this series, how- The amount of solution employed de- ever, were cases of genuine post-opera- pended on the individual case, but the tive pyelitis. average amount was from 8 to 10 c. cm. Group 3. Patients who had been of a 0.5 to 2 per cent solution. The operated upon many years before they lavage was usually done twice a week came under observation. or at five-day intervals until the urine Group 4. Patients who had had kid- was sterile on three successive tests. ney operations ; in four there had been As it is a well-recognized fact that a nephrectomy with resulting pyelitis conditions of the gastro-intestinal tract in the remaining kidney in each case. such as chronic constipation, colitis. In cases of acute colon bacillus pyelitis etc., produce lesions of the urinary tract, instrumental or local treatment was not routine examination of the rectum for resorted to, the one exception to this haemorrhoids, fissures, etc., of the pros- rule being the pyelitis or pyelonephro- tate and seminal vesicles in the male, sis of pregnancy. The treatment of and of the female genitalia followed by chronic pyelitis may be considered un- appropriate remedial measures of pa- der the following heads: vaccine ther- thologic conditions found was of ma- apy, medical treatment, and pelvic lav- terial benefit in clearing up the renal age. Early in this work vaccines were infection. used in conjunction with other forms of The author's summary is as follows: treatment, but as it soon became evi- i. Pelvic lavage with silver nitrate is dent that they were not of great value an efficient and simple method of treat- they were discontinued. Since then the ing infections of the renal pelvis, author finds that the results have been 2. In the series of cases reported, 66.4 204 SOUTHERN MEDICINE AND SURGERY April, 1922. per cent of the patients treated were God's wrath, and gave him the feeling finally discharged with urine sterile and of some measure of identification with free from pus. God's son. 3. In selecting cases for treatment, The supposed epileptic traits to which lesions of the urinary tract which are specific reference is made are his great of a surgical nature must be excluded, desire for re.cognition, and his love of 4. Lesions of the abdominal viscera domination, his hypersensitiveness, ego- which may be factors in contributing tism, vanity, emotional poverty, nar- to relapses or rendering this treatment rowness of view, pedantry, rigidity of inefficient must be recognized and sub- opinion, scantiness of ideas, limited vo- jected to appropriate treatment. cabulary, preoccupation with trifles, 5. Special stress must be laid upon outbursts of temper, and inability to proper attention of lesions of the gas- get along with his fellow-workers. The tro-intestinal tract. author seems to think that only Tim- 6. Lesions of the male and female othy and Luke could live in any sort genital tract must receive proper treat- of harmony with Paul. Timothy was ment. youthful and easily dominated and the 7. Careful routine examinations of author intimates that Luke might have the urine in all cases of obscure abdom- been a passive homo-sexual. inal pain should be made before the The article does not indicate either a patient is subjected to surgical opera- Profound or a sympathetic knowledge of tion. C. D. Holmes, M.D. the great evangelist's writings or of his ^ personality, but it will enable one to un- Mental and Nervous James K. Hall, M. D., Dept. Editor derstand the new angle from which psychoanalysts are viewing human be- ings. Psychologic investigation is be- ing made nowadays of the dead as well At the last Christmas season this as of the living, of the saint as well as Department Editor received from the of the sinner, and the new democracy hands of a generous friend a copy of insists upon making its own estimates, the "Life and Letters of Saint Paul," Perhaps the unconscious motive is to by the Reverend David Smith, D.D. A bring about a leveling process — by find- reading of the volume has increased the ing in the super-man some of the de- writer's admiration for the great Apos- fects of ordinary man — and in that way tie. In the recent January number of to establish the feeling of universal the Psychoanalytic Review the editor equality so comforting to all of us. has read with interest and considerable surprise a brief outline of the Apostle's In the Journal of the American Medi- personality from the point-of-view of a cal Association for March 25, an article psychoanalyst, by Cavendish Moxon, of is contributed by Dr. C. M. Byrnes, of Los Altos, California. He writes under Johns Hopkins Hospital on the treat- the following captain: "Epileptic Traits ment of multiple sclerosis. For some in Paul of Tarsus." In the beginning time Byrnes has been inclining to the he refers to Nietzche's estimate of the belief that multiple sclerosis is an un- morbid elements in the Apostle's make- usual manifestation of syphilitic in- up, and he quotes Pfister's opinion that volvement of the central nervous sys- Paul's conversion was a neurotic mani- tem. In this belief he has recently had festation, and that the new theology in- the support of the mighty influence of troduced by the Apostle was a reaction W. G. Spiller, who has gone so far as against his own repressed desires, to advise the administration of anti- Moxon thinks of Saul as being under syphilitic treatment in cases of insular the uncomfortable domination of cere- sclerosis. monialism and morbid scrupulosity, and Byrnes reviews in detail five cases in his experience on the road to Damascus which the diagnosis of multiple sclero- suddenly liberated him from his fear of sis was made by him and by others, April, 1922. EDITORIAL and in which specific treatment was given. In the first case there had been a chancre six years before the man came up for the diagnosis of multiple sclerosis, but active treatment was in- 205 Orthopaedics Alonzo Myers, M. D., Dept. Editor stituted and the syphilis was apparently Infantile Deforming Osteochrondritis cured. Spasticity developed in the low- of the Upper Femoral Epiphysis. er extremities, with ankle clonus and Feutelais — Revue d'Orthopedie, July, Babinski on each side, and with inten- 921. tion tremors in the upper extremities. A child with negative family and per- Under syphilitic treatment he recover- sonal history began to limp when about ed. In the other four cases the diagno- -^^2 years old and at the same time an sis of multiple sclerosis seemed likewise appreciable atrophy of the left leg and justified. Three of these cases were buttock was noticed. No pain, except supposed never to have had syphilis, for a very short period at the begin- and Wassermann tests were negative, ning. The limp resembled that of a In the one case of preceding lues the dislocated hip or a coxa vara. Motion symptoms of sclerosis developed five in the left hip to normal limits except years after the luetic infection. This that abduction is very sharply limited, infection was promptly and vigorously (Rotation is not mentioned.) The treated, and was apparently eradicated, roentgenogram showed a slight coxa In case numbered 2 specific treatment vara and the epiphysis reduced to a thin was followed by such improvement in plate of tissue in three pieces. The ace- the symptoms of multiple sclerosis that tabulum showed roughening on its su- the man resumed work. In case num- perior surface. bered 3 specific treatment brought no The child had no immobilization of improvement but the man was reported the hip but went about as a normal by his family physician to have got child. After two years there was no better after taking thyroid gland. In more limping except perhaps in wet case 4 treatment with salvarsan was weather. The child was so well that followed by such dangerous reaction the mother did not worry any more that the medication had to be stopped, about it. All the sclerosis symptoms became In this case there was no trace of in- worse, fection found and no history of trauma. Byrnes reviews rather fully the liter- ^^ ^as not congenital. The affection is ature dealing with multiple sclerosis regarded by the author as a defect in and he comes to somewhat the follow- osteogenesis and as probably analogous ing conclusions: the pathology and the ^o imperfect development of the tarsal symptomatology of multiple sclerosis re- scaphoid which is frequently seen in sembles that oif syphilis of the central young children. nervous system; the lesion of insular «« w i /^ ^ T" j ' . r, j c^^r.^ ; ■ f • a 4. 4. J Multiple Osteochondromata — Bernard sclerosis is of inflammatory type, and „• iir-j t»* t^ * t h fv,^ „^- „, fl .J u I, • • 1-1 \.u ^ f Pierre Widmann, M.D., Am. Jour, of the spinal fluid behavior is like that of Roentgenology, August, 1921. syphihs but for the absence of a posi- ^^^ ^^^^^^ f; f ^^; ^^^^ ^^ ^^.^ tive Wassermann. Attention is called j-.- u- u u j ^ umu 4-r. -t-v. f i- 4.U ^ i. 1 ■, condition, which he defines as "The oc- to the fact that every case of syphihs ^^^^^^^^^ ^^ ^^j^. 1 ^^^^ ^^ ,^^^ of the central nervous system does not ^^^^j^^, cartilaginous and osteo-carti^ give a positive Wassermann. , • ., -^.u- j 4.x. T^ lagmous growths, within and on the Byrnes thinks finally that if syphilis skeletal system, generally benign and be not the cause of multiple sclerosis resulting from a disturbance in the that there are undoubtedly cases of proliferation of bone forming cartilage." patchy syphilitic involvement of the Heredity evidently plays a consider- central nervous system which cannot be able role in the transmission, and tu- differentiated from genuine multiple berculosis is frequently associated, sclerosis. which association may be significant. 206 SOUTHERN MEDICINE AND SURGERY April, 1922. In the case reported, a boy of 13, paralysis of the orbicularis recommend- there was neither hereditary nor tuber- ed by Lint for intraocular operations cular element, nor any significant pre- with good results. He advises its use vious sickness. He began to present in cataract extractions, and other intra- bony enlargements at four years of age ocular operations, as it obviates the at the wrists, knees, ankles, over the danger of loss of vitreous and other clavicles and the inferior angles of the dangerous accidents, caused by a squeez- scapulae. There were no subjective ing together of the lids. He makes an symptoms. injection of a 2 per cent solution of The roentgenologic examination novocaine by introducing the needle at showed disturbance in the ends of the a point a little external to the outer, diaphyses of all the long bones, even lower angle of the anterior margin of the ribs, in the nature of thickening or the orbit, passes it by the upper margin tumor formation, having the character- of the orbit, 1/2 c.c. of this solution is istics of bone: i. e., cancellous tissue, injected into the muscle as the needle regularly arranged, with no destructive is withdrawn ; the same thing is done effects and none of the appearance of along the lower margin of the orbit. In true tumors. fifteen minutes the orbicularis muscle Two cases of multiple exostoses are is paralyzed enough to prevent reflex on record, in which there were endosto- closure of the lids. The function of the ses pressing on the central nervous orbicularis returns in one hour. Rochat system, causing pressure symptoms. has gone further and after cocannizing The author's conclusion is that this the eye, injected the superior recti mus- condition is a constitutional disease, des with a 2 per cent novocaine solution primarily a disease of the endocrine to prevent upward rolling of the eyes system, and with an hereditary ten- in cataract operations and iridectomies, dency. It is unnecessary to inject the inferior oblique. Usually the sensory nerves alone are paralyzed, so that reflex move- ments are inhibited, the motor nerves and voluntary movements are not af- fected. Eye, Ear, Nose and Throat J. p. Matheson, M. D., Dept. Editor New Method of Preventing Post Opera- tive Intraocular Infection — G. H. The Ocular Manifestation of Multiple Bell— Journal A. M. A., Oct. 1, 1921. Sclerosis— Dr. Mark A. Holden, Ar- Bell reports four hundred operations chives of Opthalmology, March, 1922, without a primary infection. His meth- P- 114-119. od is to drop one per cent silver nitrate Pupilliary anomalies in multiple into the eye two hours before operation, sclerosis are rare. Palsies of the ocular He thinks that the silver stimulates the muscle??, are found in but 20 per cent of conjunctival tissues to produce a leuko- ^he cases, are of nuclear origin, are fre- cytosis and protective substances are Quently transsitory and have no fea- formed, which take care of the micro- tures that are characteristic. Nystag- organisms if anv are present. He does ^us and nystagmoid twitching is found not hesitate to operate even when the ^ almost all advanced cases, smear shows bacteria. He emphasizes Optic nerve symptoms of multiple the importance of looking after what he sclerosis have long been known and the calls the three T's, teeth, tonsils and chief advance in our knowledge of them, toxaemia, as the causes of infection. recently, has been in the greater pre- cision in determining the defects in the Akinesia in Eye Operations— Rochat visual field and in the earlier recogni- Klin. Monatsbl. f. Augenheilk, Aug.- tion that the symptoms are dependent Sept., 1920, p. 177. upon the disseminated disease of the Rochat has' often used the temporary central nervous system. April, 1922. SOUTHERN MEDICINE AND SURGERY 207 Holden refers to a very important are not destroyed, restitution of vision paper on the subject by Klingmann frequently takes place. In the early (Journal of Nervous and Mental Dis- stages if the inflammatory plaque is eases, 1910, No. 12). The latter gives near the optic disc, there may be con- in detail the histories of twelve patients gestion or a low degree of edema of the with unquestionable multiple sclerosis, disc ; but if the plaque lies far back in in which visual disturbances were noted the nerve, the disc for a time appears early. His fields were carefully taken normal. After from one to six weeks with very small test objects and many pallor of the disc becomes permanent, absolute multiple scotomata are found even though vision is restored to nor- in or near the point of fixation and mal. rather more numerous in the temporal Three varieties of pallor: (1) a per- than in the nasal portion of the field, manent whiteness of the disc in its en- With his small test objects, he found tire extent; (b) a slight pallor of the as many as sixteen minute absolute disc in its entire extent; (c) a pallor scotomata, in cases in which earlier ex- of the infero-temporal third of the disc aminers might have noted only a single with the other two thirds normal in large diffuse relative scotoma. The color. In some cases of multiple sclero- tendency today is to use small test ob- sis, pallor of temporal half of visual jects and thereby obtain more accurate field is marked, and yet the visual acuity fields. and field of vision are normal. The symptoms on which Klingmann Fields of Vision — Three types of field insist as corroborative of the diagnosis defects: (1) peripheral contraction; (2) of multiple sclerosis, when a central central or paracentral scotoma; (3) a scotoma is found, are ankle clonus and combination of both central and peri- the Babinski toe reflex. The author is pheral defects. The central and para- surprised that in no case history does central field defects are the most char- Klingmann mention the state of the acteristic. May find almost any field abdominal reflexes, "Yet," Holden af- defect late in the progress of the dis- firms, "diminished abdominal reflexes ease. are found in multiple sclerosis as fre- Course and Diagnosis — Onset is acute quently as the Babinski toe reflexes; in half the cases, and a large percent- namely, in about 80 per cent of cases." age in both eyes. Maximum disturb- If we exclude diminished abdominal re- ance of vision may be reached in a fev< flexes found with hysterical anaesthe- days and recovery takes place in equal sia, and if we eliminate the other com- time. The disturbance of vision may mon causes of central scotoma, the pres- long remain stationary, then even im- ence of central scotoma and diminished prove or grow worse, and remissions, abdominal reflexes warrants the diagno- relapses and extensions may alternate sis of multiple sclerosis on these symp- for years. Unlike atrophies of the optic toms alone. nerve of other origin this variety never leads to blindness. Optic Nerve Changes — The charac- "In summing up," to use the author's teristic plaques develop in the optic own words, "we may say that defective nerve or tract at any point, but with vision in one eye or both, generally of great frequency in the fibre bundle of acute onset and mostly with one or the optic nerve. The later is a very more small scotomata at or near the sensitive bundle and especially vulner- point of fixation, is a common symptom able to toxic agents or to pressure. of multiple sclerosis that may come on In the plaques, the inflammatory ex- at any time, but often appears early in udation at first merely compresses the the disease. A rhinological examination optic nerve fibres and interferes with should exclude the paranasal sinuses as their function. Later, the medullary causative factors and then in many sheathes break down and the glia tissue cases we must exclude hysteria. The proliferates, but since the axis cylinders early organic signs on which we rely for SOUTHERN MEDICINE AND SURGERY April, 1922. the exclusion of hysteria are diminution of the abdominal reflexes and the pres- ence of Babinski reflex and ankle clo- nus." Hospital and Sanatorium John Q. Myers, M. D., Dept. Editor Reviewing Dr. G. G. Goldwater's Corresponrence Before placing a hospital on its list of institutions approved for internships, the Council on Medical Education and Hospitals is accustomed, I believe, to satisfy itself by careful inquiry that the hospital possesses the necessary fa- cilities, staff and organization to do the required work. To this end, competent persons are sometimes called on to tes- tify to the hospital's fitness. If similai inquiries were made in order to test the fitness of medical schools to carry on undergraduate teaching, what would be the result ? I ask this question in all seriousness, after reading The Journal's account of the discussion that took place at the re- cent Annual Congress on Medical Edu- cation, Licensure, Public Health and Hospitals. The participants in the dis- cussion are men who are responsible for the administrative policies of medical schools, yet not one was prepared to maintain that medicine is being satis- factorily taught anywhere. With this testimony many will be inclined to agree. What, in brief, is the nature of cur- rent medical teaching? The medical student is first introduced to the funda- mental sciences — biology, chemistry and physics. Next he is taught physiology and anatomy. He learns about the nor- mal human body, its structure and func- tion. If, at this point, it were possible to ignore tradition, the medical educa- tor would be tempted next to direct the attention of the student to health con- servation or preventive medicine. If the promotion of physical well-being is the aim of medicine (the "prevention, cure and alleviation of disease," in dic- tionary parlance), would it not seem to be logical, after familiarizing the medi- cal student with the healthy body, to show him how, during infancy, child- hood, adolescence, maturity and old age, the vigor of the body can best be main- tained? Time would be well spent in the study of the manifold dangers that threaten infancy, that lurk in the path of youth, that frustrate and embitter age, in all the walks of life. But how many medical schools today undertake broadly to teach health conservation? The space allotted to hygiene and tha various aspects of health conservation in the current medical curriculum is al- most negligible. Passing lightly over these subjects, the student is conducted all too quickly to the clinic and the post- mortem room. And when finally, in the hope of rounding out his practical train- ing, he enters the hospital as an intern, his mind is firmly set toward the more dramatic phases of disease and injury. In the hospital, fully half the time and attention of the intern is claimed by major surgery — a useful, indispensable and life-saving art, but one which, if appraised, would probably be found to embrace from one-thirtieth to one-fifti- eth of the potential usefulness of med- ical science, broadly conceived and stra- tegically organized and Applied. On a number of occasions I have ask- ed men engaged in the teaching of phy^ sical diagnosis whether in the presenta- tion of this subject it was not a mistake to stress well-marked pathologic condi- tions. These men have usually agreed that much could be gained by increased attention to the study of the body from the standpoint of health rather than from that of disease, but they have maintained that the medical curriculum is already so full that it is impracticable to add anything to it. Nevertheless, it is noticeable that whenever a new, strange and remote tropical disease makes its appearance, some member of the faculty is sure to find the time to tell all about it, however slight the ben- efit that is likely to result from its pres- entation to a group of students who are preparing to practice medicine where the disease in question can never be April, 1922. ^ BDITORIAL ^ 209 more than a rare curiosity. Meanwhile, cal education, with a view to the presen- the teaching of personal hygiene is left tation in logical order of (1) the to public health organizations, which sciences underlying medicine; (2) an- lack the numbers, the intimate personal atomy and physiology; (3) the science contacts and the forceful influence of and art of health conservation, and (4) the great body of educated physicians, the diagnosis and treatment of disease. It is my belief that radical changes The multiplication and expansion of in medical education, organization and schools of public health, however use- work are required for the most effective ful and desirable, will not meet the re- application of medical science, and that quirement. an essential prerequisite is a change in . — ^ Roentgenolog^r Robt. H. Lafferty, M. D., Dept. Editor the aim, content and method of medical education. Progress in this direction will, however, be extremely slow, unless the public becomes aware of the situa- tion, and demands a type of service In the March number of the Journal which today the graduate of the stand- of Radiology the last paper read by Dr. ard medical school is hardly prepared to J. G. Van Zwaluwenburg is published, render. Medicine itself, not public As with all of his publications, this is health administration only, must accept much above the average paper. The in good faith and must practice in all title of the paper is: "Pyelycography : earnestness the whole duty assigned to Its Field and Its Limitations." He used it by common sense, as well as by the the word "Pyelcography," derived from dictionary, namely, the duty of "pre- the Greek word, "pelyco," the pelvis, venting, curing and alleviating" disease It is using pneumoperitoneal methods in (not curing disease only). Medical so- examining the female pelvis, cial service, so called, is an entering The following is an abstract from this wedge. Prenatal work is another step journal : in the right direction, and in this field, A direct comparison between explor- happily, many physicians are fairly atory laparotomy and pneumoperito- awake to their responsibilities and op- neum is not justified, in the author's portunities. In pediatrics, a hopeful be- opinion. If the earlier data of the for- ginning is found in the "health classes" mer method were compared with the for infants and children. The methods data obtained on pneumoperitoneum the of some tuberculosis dispensaries, and comparison would be more nearly fair, of certain psychiatric clinics, are quite The information one may hope to gain advanced. The systematic supervision by either method must be taken into of the health of groups of industrial consideration and not simply the dan- workers is another promising sign. Life gers of the two methods compared, insurance companies are lending a hand On the other hand proponents of in- by providing means for the periodic ex- flation are under obligation to prove amination of policy holders. But the that their method is much less danger- object sought will not be attained until ous than surgical procedure because of the principles and practice of health the fact that the information obtained conservation find a place in the medical by the X-ray is less than that by lapar- curriculum as a major subject, to be otomy, and until the method is in use pursued intensively before the student longer its lesser danger cannot be is permitted to concentrate on pathol- proved. ogy and the practice of medicine and Something over three hundred cases surgery, as now taught. have been inflated at the University of Let me make it perfectly clear that I Michigan Hospital up to date, with no am not asking only for increased em- harmful results of any kind, phasis on hygiene in the present curri- The introduction of gas by way of the culum, but for a fundamental recon- uterus is free from objections ordinar- struction of the whole scheme of medi- ily brought against abdominal puncture. 210 SOUTHERN MEDICINE AND SURGERY April, 1922. but there is danger of carrying infec- corrected to read complication by ex- tion along the fallopian tubes and into trauterine condition, the peritoneal cavity and also there is The method has several bearings the danger of inducing abortion. There- upon pelvic tuberculosis, also the pa- fore, in all cases of suspected pregnancy tency of the tubes in sterility and a a thorough clinical examination must be negative diagnosis in the case of neu- made before deciding on the method of rotics are valuable contributions of this inflation. The uterine method furnish- method. ed valuable information as to the con- The pelycogram is singularly sensi- dition of the tubes and the bearing of tive to relatively slight changes in mor- this upon sterility. phology and relationship of the pelvic Of the three hundred and fifty cases organs and so the pelvis which appears examined one hundred and fifty-three normal to the sophisticated X-ray eye have been confirmed either by opera- is without significant pathology, tion or by time in the case of pregnan- The best evidence of the value of the cies. In all cases the conclusions were method is the attitude of the Depart- drawn from the stereoscopic image ment of Gynecology of the University alone— an unnecessarily severe test— Hospital, which refers selected cases in though a joint opinion with the gynec- undiminishing numbers to the roentgen- ologist was arrived at before any oper- ologist, and staff disputes are being con- ation was performed. stantly settled in this way. Because the pelvic cavity is approxi- Co-operation between the roentgen- mately cone shaped, the bundle of rays ologist and the gynecologist is impera- fall from above, otherwise the ray tive and has existed in unusual degree would meet the pelvis at a broad angle, at the University Hospital. For these reasons the tube must be ^ ^^^^ complete discussion of this placed above the patient The most im- ^^^-^^^ ^^^ ^^^^^ ^^ ^^^ ^-^^ ^f portant feature of the techmque is the ^^^ ^^^^^^,^ ^^^^^^ inclination oi the patient to the hori- News Items zontal because the uterus must hang fully suspended from the floor of the pelvis so that the ray will fall vertical to the axis of the uterus. The position is not possible with every case. The ^ ,, . , ,, , „ ^ ^ bladder and colon must, of course, be , ^"l^^^ ^.^T^flJ^Z'^V'.^' ^T emDtv Cook Hirst, of the Medical Depart- _ ' „ , ^ , , ment of the University of Pennsylva- In the case of large tumors clearly ^. ^^^^ ^ invitation a paper before of the pelvis origin and m uncompli- ^^^ Richmond Surgical Society on "Sur- cated pregnancies there is little to be -^^^ Treatment for the Commonest gained by this method. On the other D^g^ases of Women." He had a large hand It IS possible to confirm the opin- ^^^ interested audience and his talk was ion of the gynecologist that an obscure inspiring to those who were fortunate abdominal mass is not of pelvic origm. ^^^^^^ ^^ ^^^^ ^.^^ Dermoid cyst and pelvic abscesses have been found in normal pregnancies with ^^ ^^^ ^^^^. ^^ ^^^^j^ ^4^ ^^^ no harm from inflation. Richmond Academy of Medicine and The demonstration of a normal preg- Surgery in regular session was address- nancy presents least difficulty between gd by invitation by Dr. Sidney P. Mil- the sixth and the sixteenth week. After ler, of the Medical Department of Johns that or before the method is either use- Hopkins. He presented the "Modern less or superfluous. Aspects of Pernicious Anaemia." He Ectopic pregnancy has presented dif- spoke informally and without notes, but ficulties in this series through the diag- he reviewed the problem from every nosis of an ectopic pregnancy has been angle — cause, diagnosis, prognosis and April, 1922. EDITORIAL 211 treatment — in thorough fashion, and his remarks were especially helpful in lessening the prognostic gloom of this condition which has been viewed here- tofore with such uniform pessimism. The Academy has not heard for a long time a subject presented with more clarity, conciseness, and withal so com- prehensively. Dr. Miller's thesis pro- voked discussions and called forth in- teresting observations from Dr. War- ren T. Vaughan, Dr. S. W. Budd, Dr. W. H. Higgins, Dr. B. R. Tucker, Dr. C. C. Coleman, Dr. W. B. Porter, Dr. J. H. Smith and Dr. J. K. Hall. On the same evening Dr. B. H. Gray reported a number of personal cases of the troublesome type of toxemia in pregnancy, and his cases were discuss- ed in interesting fashion by Dr. Vir- ginius Harrison. Dr. S. W. Budd reviewed a number of cases of malignancy of one type and another that had been treated at his hands within the past few years by ra- dium radiation. His presentations were all illustrated and in many instances the results were little less than mar- velous. Certain types of malignancy are not, however, in Dr. Budd's opinion, amenable to radium therapy, and per- haps not to any other therapy known at this time. Dr. Budd's observations were added to by those of Dr. A, L. Gray and Dr. C. C. Coleman. "A Study of Pericarditis," prepared by Dr. W. B. Porter, was read in his absence by Dr. Manfred Call. The study of the same condition from the X-ray point of view was made by Dr. Fred M. Hodges, and was illustrated by lan- tern slide demonstrations of first class quality. Both these studies called forth lively discussion from Dr. J. Shelton Horsley, Dr. A. L. Gray, Dr. D. D. Tal- ley. Dr. J. M. Hutcheson and Dr. W. A. Shepherd. Dr. W. L. Mason reported an unusual case. A colored man presented himself exhibiting a protruding and blind right eye. Examination brought to light a retrobulbar collection of a large amount of pus, which had originated in an eth- moid abscess that had ruptured into the orbital cavity. The eye was lost, but treatment resulted in recovery other- wise. At the regular meeting of the Rich- mond Academy of Medicine and Surgery on the evening of March 28, Dr. Ward H. Cook, who occupies the chair of Pa- thology in the Medical College of Vir- ginia, gave a demonstration of a num- ber of gross pathological specimens from the pathological museum of the college. This proved to be an exceed- ingly interesting innovation. A prostate gland, recently removed in one of the Richmond hospitals, weighed 285 grams, by far the largest specimen Dr. Cook had ever seen. The surgeon who did the operation was present, and he re- ported the patient, a man of 76, in good condition a number of weeks after the operation. Norfolk County Medical Society The section on Surgery and Gynec- ology of the Norfolk County Medical Society held its regular monthly meet- ing on Monday evening, February 13, 1922, Dr. R. L. Payne in the chair. Dr. .1. T. Buxton, Newport News, Va., invited speaker, read a paper on "Trau- matic Rupture of the Spleen." Dr. C. W. Doughtier There are two methods of treating rupture of the spleen: (1) Suture of the wound, which carries a mortality of 50 per cent, and (2) splenectomy, with a mor- tality of 37 per cent. The rate with- out operation is about 93 per cent. The mortality from splenectomy has shown a steady decrease, probably due to the fact that surgeons are more alert to the possibility of these injuries. The main point in these cases lies in an early diagnosis, and this is often ex- tremely difficult. The symptoms con- sist of sudden pain, faintness, nausea, and vomiting. The temperature is sub- normal and the pulse rate high, in a few cases there is dullness over the lower abdomen. The completion of this cycle of symptoms depends on the ex- tent of the injury. The blood count goes up and stays up for 15-40 days. 212 SOUTHERN MEDICINE AND SURGERY April, 1922. Dr. L. Gwathmey: Rupture of the normal spleen is very rare as compared with rupture of the liver. Rupture of a pathological spleen is much more common. Rupture may easily occur af- ter malaria, for instance. I have seen several cases of gun shot wounds of the spleen. Here the indication is to stop hemorrhage and transfuse. Then we may do a splenectomy later. In ex- treme cases I would urge this proce- dure. Dr. P. St. L. Moncure: I have had enough experience with spleens to know that they bleed most profusely and I don't believe we can temporize with them. I should take out a ruptured spleen at the earliest opportunity. I be- Heve suture of the spleen is absolutely contraindicated. Dr. Buxton (closing) : When to oper- ate is a question for surgical judgment and I do not believe we should operate on all cases at once. There is no ques- tion of the fact that a pathological spleen is more easily ruptured than a normal one. Dr. C. C. Smith read a paper on "The Use of Radium in Splenic Conditions." Dr. E. C. S. Taliaferro: It is not the total white count that one notes in luke- mia, but the percentage of normal as compared with abnormal cells. We should watch most carefully the num- ber of normal cells. If they drop below 2-3000 the prognosis is bad. I do not believe we can judge by the red count. I think it is better to use small doses of radium and watch the patient closely, as it is easy to overdo the treatment. B. E. Harrell, M.D., Reporter. belief, there is no cause and effect rela- tion between weight and thyroid activ- ity as evidenced by the basal metabol- ism tests. Weight changes apparently are determined by other endocrines — possibly the anabolic types — rather than by the catabolic group to which the thyroid belongs. The conclusions should serve as a warning against the promiscuous administration of thyroid extracts in subjects who are over- weight. Association was noted of low pulse definitely with low metabolism with gradual ascent of curve of rising metabolism with increase in pulse rate, until at 0 of metabolism an average pulse rate of 85 is recorded. After that point is reached, the metabolism shoots up with the increasing rapidity over the pulse rate until runaway pulse is reach- ed, after which it does not change much. A pulse over 82 in men or 90 or over in women in a resting state is cause for suspicion of hyperthyroidism, and a ba- sal metabolism test is indicated for final judgment and is likely to show plus. Several observations have shown that when the pulse rate drops from a high normal in action to a normal or low "basal" rate, the basal metabolism is most likely to show normal or low. The basal metabolism test is necessary for diagnosis and for therapeutic regula- tion. Its determination by tried out portable apparatus is reliable. The test is best made at the bedside of the sub- ject, and the portable apparatus makes feasible its use in the home when proper technic is employed. MISCELLANEOUS Basal Metabolism and Ideal Weight and Pulse Ratios. More than twenty-five hundred obser- vations on about twelve hundred sub- jects were made by Anne Peterson and Will Walter, Chicago (Journal A. M. A., Feb. 4, 1922). Contrary to the usual Congenital Dislocation of the Hip Henry Bascom Thomas, Chicago (Journal A. M. A., Feb. 4, 1922), re- views his results in the treatment of dislocated hips. In all, there were forty- four cases and fifty-six hips. Twenty of these cases, or twenty-six hips — the condition being bilateral in six cases — were those of patients 6 years of age or older. In this series, eighteen opera- tions were done. Reduction was effect- ed in five cases, in one of which the dis- location was bilateral. One hip was redislocated because of the development of trophic changes. Eleven hips (seven ApHI, 1922. MISCELLANEOUS 213 cases) were not treated because the prognosis was too unfavorable. One hip remained out, as attempts at manual reduction failed and the open method was not tried because the muscles were too tense. One hip is marginal. In an- other case the result is questionable. The results in seven cases are not yet known. In none of these cases was the machine or reducing table used. There were twenty-four cases of patients un- der 6 years of age. In six of these the dislocation was bilateral. Therefore, these cases included thirty hips. Forty operations were performed. Fifteen hips were reduced with a fair to good anatomic result and good function. The parents were pleased. Three hips re- mained unreduced and the patients did not return after release from the cast. In two cases the dislocation recurred. One of these patients has a fairly good function. In two cases the result is questionable. The results in six cases are not yet known because only the in- dex card was found. In one case of bilateral dislocation the anatomic re- sults are perfect and function is good, but the patient limps slightly when fa- tigued. The five cases in which the hip is still out, the two cases in which it is marginal, and the two cases in which the results are questionable should not be regarded as failures, perhaps, be- cause, as the patients are still under 6 years of age, the prospect of a suc- cessful result in another attempt at re- duction is at least fair. It is urged that all those who have had experience in the treatment of con- genital dislocation of the hip make a detailed report, thus aiding in establish- ing standards of management which cannot fail to improve our results. Announcement of the Medical Fellow- ships The National Research Council an- nounces the establishment of Fellow- ships in Medicine created for the pur- pose of increasing the supply of thor- oughly qualified teachers in medicine in both clinical and laboratory subjects and in both curative and preventive aspects. The fellowships are supported by appropriations of the Rockefeller Foundation and the General Education Board amounting in total to one hun- dred thousand ($100,000) a year for a period of five years. Those receiving awards will be known as Fellows in Medicine of the National Research Council. To qualify for appointment as a fel- low, a candidate must have the degree of Doctor of Medicine or Doctor of Philosophy from an approved univer- sity, or preparation equivalent to that represented by one of these degrees. Only citizens of the United States or Canada will ordinarily be appointed, al- though the fellowship board is author- ized to set aside this provision in ex- ceptional cases. The fellowships will be open to both sexes. Since the principal purpose of estab- lishing these fellowships is to increase the number of competent teachers in the field of medicine, each incumbent will be required to gain experience in teaching. As creative work is regarded as essential to the best teaching, em- phasis will also be placed upon research. Fellows will be at liberty to choose the institutions or universities in which they will work, as well as the men under whose direction they will carry on their researches, subject to the approval of the fellowship board. Appointments are to be made for a period of twelve months, beginning at any time in the year, with an allowance of six weeks for vacation. The time may be extended, however, if in the judgment of the board the work which the fellow has done justifies it. The stipends are not definitely fixed in amount; but they are intended to en- able the individual to live comfortably while carrying on his special work as a fellow. The fellowships will be administered by a special committee, known as the Medical Fellowship Board of the Na- tional Research Council. Correspondence concerning the fel- lowships should be addressed to the Division of Medical Sciences, National Research Council, Washington, D. C, 214 ■-' ^ 1 SOUTHERN MEDICINE AND SURGERY April, 1922. School of Hygiene and Public Health, cent to the Johns Hopkins Medical The following is authorized by Edwin R. School and Hospital. Embree, Secretary of the Rockefeller Founda- j^ ^ju ^g remembered that the Rocke- '°The Rockefeller Foundation has given feller Foundation was also one of the six million dollars ($6,000,000) to Johns donors to the School of Public Health Hopkins University, Baltimore, for en- of Harvard University. The Founda- dowment and buildings of the School of tion's gift of two and a quarter million Hygiene and Public Health. dollars to that school, announced last Since this School was opened in 1918 summer, made possible reorganization the Foundation had furnished the funds and development of an institution al- required for its maintenance from year ready established with other funds. to year. With the acceptance of the present gift the trustees of the Univer- Hemorrhage as a Form of Asphyxia sity assume full responsibility for the The data on which this paper is based future needs of the school as they de- were taken from a very large amount velop. of material collected by Yandell Hender- This new type of institution places son and Howard W. Haggard and their emphasis upon the development of pre- collaborators, New Haven, Conn. (Jour- ventive medicine and upon the training nal A. M. A., March 11, 1922), for the of health officers. Under the direction Shock Committee of the National Re- of Dr. William H. Welch the school has search Council during the war. A made substantial progress in the four standard hemorrhage was first worked years since it was established. Twenty- out. The amount of hemorrhage re- seven states and ten foreign countries quired to bring an animal to the dan- are now represented in the student body ger point (28 or 30 mm. arterial pres- numbering 131. The faculty of the sure) varied in different subjects from school comprises scientists in the fields 3.8 to 5.8 per cent of body weight. Hav- of bacteriology and immunology, sani- ing established this standard hemor- tary engineering, chemical hygiene, rhage, various treatments were tried in physiological hygiene, medical zoology, order to determine whether, and to what epidemiology, vital statistics and public extent, they improve the chances of re- health administration. covery. Morphin, even in moderate The regular courses of study lead to ^^^ses markedly increased the mortal- the degrees of Doctor of Public Health, '^y- Inhalations of carbon dioxid stim- Doctor of Science in Hygiene, and ^^^^^^ respiration and induced marked Bachelor of Science in Hygiene. A cer- ™Provement in the general condition tificate in public health is given to those «^ the animals for a short time; but if completing certain special courses, ^he inhalation was pushed at all, the Short courses or institutes are provided animals invariably died by vagal inhi- for health workers in service who can- b^tion of the heart. Intravenous mfu- not be absent from their positions for sion of several of the common fluids was more than a few weeks at a time. Last ^1«« .^^^^f; The volume of the infusion year thirty-six health officers from ^^^ '"^ ^^^ ^^«^« ^^^.f^?^ ^' ^^/^ °^ ^^^ eight states took these short intensive ^lood previously withdrawn from the courses animal. Physiologic sodium chlorid so- ' , . ,. ,, , ,1 , lution was only temporarily beneficial. Up to this time the school has been ^^^.^^ bicarbonate solution (2 per housed m old buildings situated in the ^g^^) ^^^^ ^ ^^^^ ^^^^^^ showing, centerofthecityof Baltimore, and for- ^^^^j^ ^^1^^.^^ ^^^ ^^^^^ distinctly merly used by Johns Hopkins Univer- beneficial immediately after injection, sity for laboratories of physics, chemis- r^^^^^ ^^-^^j^ ^^.^^ received it were, try, and biology The present gift, in however, usually found dead the next addition to providing endowment, will ^^rning. From these experiments as a make possible the erection of the new whole it appears that the most that in- building for the school on a site adja- fusion of artificial solutions can accom- April, 1922. MISCELLANEOUS 215 plish is replacement of plasma more perfectly willing to admit this; it is quickly and perhaps more completely equally willing to admit that the vast than the body itself could manage by majority of those who die, die in bed. withdrawing fluid from the tissues. On Neither of these somewhat self-evident the whole, the results obtained with the propositions, however, argues that sci- inf usions were scarcely better than with entific medicine is more dangerous than no treatment at all. chiropractic, "Christian Science" or os- teopathy, or that a bed is a dangerous Epidemic (Lethargic) Encephalitis, place. They do prove that most people In the experience of George E. Price, who are sick enough to be in danger of Spokane, Wash. (Journal A. M. A., death are usually in bed and under the March 11, 1922), fatigue has been a po- care of a physician. Any one who is tent factor in producing relapse of epi- familiar with the facts may admit that demic encephalitis, a long automobile comparatively few people die while di- ride immediately preceding a marked rectly under "chiropractic adjustment" recrudescence in two instances. In the or any other of the fad "treatments." case reported, more than one and one- There are two outstanding reasons for half years elapsed between the disap- this. The first is that the man who re- pearance of all symptoms and their re- lies, for example, on chiropractic for the currence. It is the longest interval or relief of some passing indisposition pre- remission so far recorded. cipitately deserts this cult when he real- izes that he is dangerously ill. Then Figures Never Lie — But Figurers Do he calls in a physician ; should he die. Those practitioners of the healing art he dies under "orthodox medical treat- who maintain that all pathologic condi- ment." The second reason is that, tions, from cancer to chilblains and should a patient die under "chiropractic from soft corns to hardening of the adjustment," the law would require an liver, are due to subluxated vertebrae inquest, as in very few states in the impinging on spinal nerves are repub- Union are these gentry permitted to lishing their annual batch of "statis- sign death certificates. It is notorious tics" on the chiropractic treatment of that when the "patient" of a chiroprac- influenza. The standard advertisement tor becomes dangerously ill, the chiro- runs, in part, as follows: praetor urges the family to call in a The following statistics of the 1918 physician! — Jour. A. M. A., March 11, "Flu" epidemic are respectfully sub- 1922. mitted: One of every 16 patients died under Our Knowledge of Vitamins medical treatments. Commenting on the trend of medical One of every 127 patients died under research concerning vitamins, the latest osteopathic treatments. report of the British Medical Research One of every 513 patients died under Council says: Christian Science treatments. The present situation is a curious one, One of every 886 patients died under upon which posterity will probably look chiropractic adjustments. back with great interest. We still have These figures, of course, are evolved almost no knowledge of the nature of from the inner consciousness of those these elusive food substances or of their gentlemen that furnish verbal ammuni- mode of action, but we have gained em- tion for chiropractic advertising cam- pirical knowledge already of the great- paigns. But, even assuming them to be est practical value for the prevention of correct, just what do they prove? They scurvy and of other grave diseases and prove that many more people die when for the promotion of health and beauty under the care of a physician than die in the population. when under the care of an osteopath, a This statement, it will be noted, em- Chrlstian Science practitioner or a chir- phasizes the foundation on which rests opractor. The medical profession is our present use of vitamins. From time 216 SOUTHERN MEDICINE AND SURGERY April, 1922. to time The Journal has commented on our lack of actual knowledge of these mysterious substances, emphasizing particularly the generally accepted fact that the taking of a well-balanced diet results in providing the individual with such vitamins as are necessary to his growth and nutrition. Last week ap- peared a brief report of a meeting of the Chicago Medical Society devoted to this subject, and it was gratifying to have the conservative view which The Journal has emphasized substantiated by many of those who took part in the discussion. Moreover, the British Med- ical Journal, in its leading editorial for February 11, reiterates that an abund- ant supply of vitamins exists in all fresh vegetables, and that a considera- ble quantity occurs in milk and meat, provided the latter substances are ob- tained from animals fed on fresh foods. "A normal adult," it says, "living on an ordinary diet containing a reasonable proportion of fresh vegetables is, there- fore, certain of obtaining a plentiful supply of vitamins." Of all the mass of evidence which has accumulated rel- ative to these substances, this fact is the point of greatest importance. It is, however, very unfortunately, the one point which those commercially inclined are unwilling to recognize. — Jour. A. M. A., March 11, 1922. Bluish Discoloration of Umbilicus In 1919, Cullen called attention to a "bluish discoloration of the umbilicus as a diagnostic sign where ruptured ex- tra-uterine pregnancy exists." Some re- cent experiences with extra-uterine pregnancy have convinced Emil Novak, Baltimore (Journal A. M. A., March 4, 1922), of the value of this "blue belly- button" sign of Cullen. He reports two cases and calls attention to the fact that Cullen's sign would hardly be positive in cases of extra-uterine pregnancy which are not associated with intra- peritoneal hemorrhage of considerable degree. Furthermore, severe intra-ab- dominal hemorrhage due to other causes than extra-uterine pregnancy might cause the umbilical discoloration as well. Cases of the latter type, however, are so rare that, to all interests and pur- poses, the sign may be considered one especially applicable to the diagnosis of ruptured extra-uterine gestation. Smallpox Washington, D. C, March 20, 1922.— The Department of Commerce, through the Bureau of the Census, announces that there have been very few deaths from smallpox in recent years. Since the beginning of annual compilations in 1900 the highest rate- from this cause in the death registration area of the United States was 6.6 per 100,000 pop- ulation in 1902, while in 1903 it was 4.2 and in 1904, 2.1, since which time the rate for the registration area has never reached 1 per 100,000 population. Much higher rates in certain states and cities, however, clearly show that the danger of smallpox in an unvaccinated population must not be lost sight of. The high rate (9.2) in 1920 in Louis- iana should serve as a warning. What Ought the United States Pharma- copeia to Contain? Oliver T. Osborne, New Haven, Conn. (Journal A. M. A., March 4, 1922), urges the revision committee to make the new revised Pharmacopeia of small size, a standard for useful drugs; and he offers a list of substances, drugs and preparations that may well be deleted from the tenth revision, including sub- stances which cannot be standardized, spices, chemicals, such as ferri chlori- dum and zinci chloridum, and many other drugs and preparations some of which are without useful activities and a few of which have dangerous activi- ties. Some were once much used and have now gone into innocuous desue- tude; some catered to the belief in the mysterious; some are preparations of really useful drugs, but in such prepara- tions the drugs are much less valuable than in other preparations, and there- fore these preparations are superfluous; some few were officialized because the demand for them was created by phar- maceutic and nostrum propaganda; some multiple mixtures were retained in the last Pharmacopeia which should be deleted from the tenth revision ; some April, 1922. MISCELLANEOUS 217 of these preparations are ancient and honorable, but have as yet retained their respectability, while others, though ancient and honorable, have lost caste. Why keep the honey in massa f erri carbonatis ? Why keep the serpen- teria in tinctura cinchonae composita? Why keep the aloes in tinctura benzoini composita? Osborne says it would be little less than the beginning of the mil- lennium to have the tenth revision of the United States Pharmacopeia of such a convenient size, containing only use- ful drugs (i. e., drugs and preparations that are known to have some medicinal value), that every physician would have it on his desk for constant use. Collection and Preservation of Human Milk Paul W. Emerson, Boston (Journal A, M. A., March 4, 1922), reports the ex- perience of the Boston Floating Hospital in the use of a dried human milk for nurslings. Two methods of preserving human milk were considered. The first one, that of evaporating the milk and adding sugar as preservative, thus mak- ing a human condensed milk, was not considered practicable. The second method, of preserving the fat alone, and homogenizing it with cow's skim milk, proved to be a good one. By combining a 12 per cent fat from human milk with cow's skim milk, and adding lactose, a milk is obtained which has the formula: fat, 3 per cent ; sugar, 7 per cent ; pro- tein, 1 per cent. This is made up as follows: 12 per cent human milk fat, 160 c.c. (51/2 fluidounces) ; fat-free cow's milk, 205 c.c. (7 fluidounces) ; sterile water, 285 c.c. (9V-> fluidounces) ; lac- tose, 36.5 gm. (563 grains). A gain in weight equivalent to that obtained with whole breast milk was the result. Em- erson suggests that such milk might be used to advantage with babies who have an intolerance for cow's milk fat; but the milk preserved in this way is ex- pensive and difficult to prepare. tion to the movement in Germany for making the study of English compul- sory in German schools. Until now French has been the compulsory foreign language. The editor says that scien- tific research in the United States has made great advances, thanks to the wealth of the country, and that Ameri- can literature is on the point of taking the lead in medicine. "The young medi- cal man planning to settle in other coun- tries," he says, "had better be trained in English, which is the predominant language on four continents, rather than in French, as German medical men may be long debarred from settling in French speaking countries." It is gratifying to have this German recognition of Amer- ica's leadership in scientific research ; it is so diff'erent. — J. A. M. A., March 4, 1922. A Recognition of American Leadership in Scientific Medicine In a recent issue, the Munchener medizinische Wochenschrift calls atten- Is the Control of Diphtheria Leading to Eradication? James Gordon Gumming, Washington, D. C. ((Journal A. M. A., March 4, 1922), maintains that the eradication of diphtheria will not come through the serum treatment of patients, by the im- munization of the well, or through the accurate clinical and laboratory diagno- sis of the case and the carrier followed by quarantine; rather it will be attained through the mass sanitary protection of the populace, subconsciously practic- ed by the people at all times. The con- tinuous blocking of transmission from the mild unrecognized case and from the unidentified carrier will reduce the case rate and the mortality rate. The accurate diagnosis and quarantine hold distribution in check; yet these methods only limit the ravages of an epidemic, and do not tend to the prevention of epidemics by a reduction in endemic in- cidence. A reduction in the endemic carrier index — the interepidemic case and carrier rate — is the end to be at- tained. The epidemiologists of labora- tory and field experience must deter- mine the major avenues of distribution and devise practical methods for block- ing these avenues. Only when these methods are inculcated into the habits and customs of the people will there 218 ' 1 SOUTHERN MEDICINE AND SURGERY April, 1922. appear a reduction in the endemic in- Trachoma dex, and successful control of diphthe- By Dr. R. I. Uhle, Bayadji-Kuey, Turkey, ria leading to eradication. There will An interesting discussion of the th^n be a reduction in the number of treatment and care of trachoma patients sources, in transmissions, in new car- in the famine stricken districts of the riers, in new cases, and in deaths. By Near East is given in an article written this endless chain of cumulative reduc- by Dr. R. T. Uhle, of Narth Carolina, tion, the disease can be brought under an eye, ear, nose and throat specialist, permanent control, as has been done in who was sent to the Levant by the Near typhoid. East Relief to alleviate the suffering of victims of Turkish massacres and de- struction. Backward Children ^^ September, 1920, the first tracho- Backward children are not always, ^^ f^^'^'l^^^^'! ^^/"^^^^^ ^^ *^f ^^^l perhaps not often, backward because of East Rdief s trachoma hospital at either mental deficiency or slothfulness, ^ayadji-Kuey, says Dr. Uhle. This says the U. S. Public Health Service, l'^''^'}^^ '' beautifully located on the Many of them are backward solely be- Bosphorous and is about five miles cause of such ordinary and easily reme- from Constantmople. The hospital is diable defects as adenoids, near-sighted- "^w filled to its capacity-250. ness, or bad teeth. The treatment of trachoma is medi- A case in point was recentlv reported ^^^ ^"^ surgical-medical predommat- by the official representative of the l^^" OP^rating selected cases shortens Public Health Service in the ^ig^th ^^^ '"'^''^'^f ^}}^ ^'^^^'^\^''^ '^'^ ^^''l sanitary district of Vermont, in which f'T' faction and ong continued the service is co-operating in a rural treatment must be faithfully carried health work project. «"*■ ^^\ "^°^^ fortunate patients re- -_-.,. ■ ^ ^ , , cover in two or three months but re- Medical mspection of one of the grad- -^^ treatment for a period of years. ed schools m October, 1919, showed that g^^^ cases as required it we treated It had been thought necessary to m- surgically, all of the younger children struct m a special room sixteen pupils ^eing operated upon under a general who had seemed to be unable to keep anaesthetic, their tonsils and adenoids up with their respective classes. Phy- removed when found, and then medical sical examination showed that each of treatment instituted. A Syrian doctor the sixteen had some serious hamper- ^^^ employed as interne, Armenian and ing physical defect (chiefly enlarged Turkish nurses were instructed in mod- tonsils, adenoids or defective hearing ^^^ ^^^^-^^ methods. The women of or eyesight) which, rather than any ^^^ ^ear East make good nurses, par- mental handicap was the probable tj.^i^rl f^, ^^,k. A delicate cause of their inability. ^^^^^ -^ required, and generations of Through the co-operation of the rug weaving and needle work have made school directors, the facts were brought their fingers very deft, to the attention of the parents or guar- a system of out-clinics was opened in dians of the children and all were set the six Armenian refugee camps, with right before the end of the year. an Armenian physician and an Ameri- On re-examination of the pupils the can nurse in charge. A central diag- next December (1920) it appeared that nostic clinic was established at the Near all of the sixteen previously backward East Relief headquarters in Stamboul. children had caught up with their This was operated once weekly and proper grades and were keeping up in cases in need of operative treatment them with their classmates. A year la- were referred here and apportioned to ter, in December, 1921, some of these the various hospitals, sixteen children were among the mental In May, 1921, it was decided that the and physical leaders in their grades. one opthalmologist with the Near East April, 1922. MISCELLANEOUS Relief was needed more in Alexandro- pol, where there were thousands of cases of trachoma with only one eye specialist doing what he could then in Constantinople, where competent eye specialists are fairly numerous. This is the situation in Alexandropol at present : The population of the camp is about 12,000; there are 2,868 cases of trachoma undergoing treatment and this includes several of the American personnel. The entire orphanage body has not been inspected, cases are re- ferred to the trachoma isolation hos- pitals by the doctors from the various ambulatories as they are reported to them. When the survey which has been instituted is completed many new cases will no doubt be found. Many blind children were recently sent to an institution for the blind. A properly treated case of trachoma will not re- sult in blindness. These are four great needs — our pres- ent isolation quarters are too small, some beds have three occupants, most beds have two occupants and a few have one. However, this is soon to be remedied by taking over Seversky Post, which will give us adequate quarters, but as the buildings are in a bad state of repair much construction is required. We need a laboratory, a technician and laboratory equipment. A well equipped central laboratory can do the work for the three different posts. Con- ditions are ideal for research. We need artificial eyes and we need X-ray ap- paratus. We need an electric lighting system, as it is impossible to do scien- tific work without electricity. Penalty for Failure to File Return. — "In case of failure to file a return on time, a penalty of 25 per cent of the amount of the tax is added to it unless the return is later filed and failure to file it within the prescribed time is sat- isfactorily shown to the commissioner to be due to a reasonable cause and not to willful neglect." Specific Penalties. — "A penalty of not more than $1,000 attaches for failure punctually to make a required return, whether of income, withholding of in- formation, or to pay or collect a re- quired tax. If the failure is willful, however, or an attempt is made to de- feat or evade the tax, the offender is liable to imprisonment and to a fine of not more than $10,000 and costs." It is the hope of this office that no tax payer will neglect this important matter and be subject to a penalty for failure to make return or delay in hav- ing it received on time. Respectfully yours, GILLIAM GRISSOM, Collector. Diamond Antiseptic Soap, introduced not long ago by Eli Lilly and Company, contains mercuric iodide and is said to be particularly well adapted for use wherever a disinfectant and cleansing agent is desired, as in disinfecting the hands and surgical instruments and in cleansing wounds. It is reported that many physicians are securing excellent results from its use in treating certain parasitic or infectious skin diseases; it is said to be useful in shampooing the hair, for the erdication of dandruff, and also as a toilet soap for general use. Unlike most germicidal agents. Dia- mond Antiseptic Soap has a pleasant odor. It produces a copious lather in hot, cold, hard or soft water. It is non- irritating, yet a fine detergent. Every physician has use for such a product as Diamond Antiseptic Soap. Eli Lilly and Company will be glad to send a samjJe on request made to the home office of the company at Indian- apolis. Milk is the universal food. In some cases it is hard to handle because the acid stomach forms indigestible clots. This curdling may be overcome without altering the value of the milk. In chy- mogenized milk the casein is precipitat- ed in floculent particles. In this form the casein is easily digested. Where the whole milk is wanted, boil, let cool to 105 degrees F. and add Chymogen. If whey is wanted heat the milk to 105 degrees F, add Chymogen. When the curd is set, cut, drain off whey and use. Chymogen is from the Armour Laboratories. SOUTHERN MEDICINE AND SURGERY April, 1922. Table of Contents for April, 1922 Original Communications Emphasis on the Stury of the Clinical Side of Tuberculosis, by Alonzo Myers, M. D._ 165 Duodenal Ulcer and Cholecystitis, by War- ren T. Vaughan, M. D. 166 Sarcoma of the Long Bones, by Jas. W. Gibbon, M. D. _: 172 Nitrous Oxide-Oxygen Analgesia and An- aesthesia in Obstetrics, by G. Bentley Byrd, M. D. 177 Some Distrubances in Pernicious Anemia Other Than Blood Changes, by Henry A. Christion, M. D. 179 The Treatment of the Emotions in Young People, by Tom A. Williams, M. D 182 Colitis, by A. T. Russell, M. D. 185 Basal Metabolic Determinations, by Car- rington Williams, M. D. 188 The Menace of Drug Addiction — Sugges- tions for Its Eradication, by Louis E, Bisch, M. D. 190 Prolapse of the Uterus, by Frank D. Wor- thington, M. D. 194 Our Best Only, by Henry Norris, M. D. 195 Editorials Higher Medical Education in North Caro- lina 197 Department Editors Gynecology and Obstetrics, Robt. B. Sei- bels, M. D. 199 Urology, A. J. Crowell, M. D. 201 Mental and Nervous, James K. Hall, M. D... 204 Orthopaedics, Alonzo Myers, M. D 205 Eye, Ear, Nose and Throat, J. P. Mathe- son, M. D. 206 Hospitals and Sanatorium, John Q. Myers, M. D. 208 Roentgenology, Robt. H. Lafferty, M. D. 209 News Items 210 Miscellaneous 212 LAWRENCE HOSPITAL AND TRAINING SCHOOL FOR NURSES C. S. LAWRENCE, M. D. W. C. STIRLING. Jr.M. D. G. CARLYLE COOKE, M. D. Chief Surgeou. Urologist. Associate Surgeon. MISS ETHEL NICHOLSON, R. N., Supt. of Nurses. MISS BEESON, SMITH, Secretary. Southern Medicine and Surgery Vol. LXXXIV CHARLOTTE, N. C, MAY, 1922 No. 5 TORSION OF THE SPERMATIC CORD 1st— Abnormal attachment of the tes- WITH GANGRENE OF THE TES- ['"^^ ^°-^^^ spermatic cord or abnormal- TICLE REPORT OF TWO ^- spacious sac formed by the tunica va- IICLL— REPORT OF TWO gmalis in which the testicle is suspend- CASES* ed, causing what is called a movable or Hamilton W. McKay, B.S., M.D., floating testis. The Crowell Clinic of Urology and 2nd— A sudden or violent contraction Dermatology, ^^ ^^^ cremaster muscle. Charlotte, N. C. Pathology A review of the literature shows the ,• ^^%^'''l^^ '^ "dually in the free por- subject of torsion of the spermatic cord , " ""^ *^.^ ^^'''^ contained within the to be both interesting and instructive 'u^ vagmalis and usually occurs from because the etiology is unknown and the ''''^^.''''l ^"^^'^^f • ^^ opening the tunica diagnosis is most difficult and frequent- ''^^'''^^'^ ^Tf ^"^ ^ blood stained fluid ly not made until operation. T }^^ ^f ''^^^ "^^^ ^^ ^"ed with blood . In a most interesting article in Gyn- '"^°^';. ^''f operator is reminded of in- ecology and Obstetrics, December, 1919 ""P^^^^"^ the abdommal cavfty where he Dr. Vincent O'Connor finds but 124 '' ^°"f^'«"^^ ^^''th either a twisted ova- cases of torsion of the spermatic cord "''"" P'^J^!" °/ ?. ^'"Ptured tubal preg- reported in all the literature but it "f"r'\ ^^^te«^>^^e ^^ reddish blue or would seem from a close study of this '''^'^^' ^^P^ndmg upon the duration, condition that it is quite frequent, how- Symptoms ever, it is generally undiagnosed before The subjective symptoms are not un- operation. Ul^g ^j^^^^ ^^ ^^^ inflammatory condi- Authors who have studied this con- tion of the scrotal contents and will not, dition and reported cases recognize two as a rule, lead to a diagnosis per se. distinct varieties : Pajn is a constant symptom, varying in J ne acute type tlegree and is usually high up in the The recurrent type. g.oin ^long the course of the spermatic Both varieties are often incorrectlv cord diagnosed as epididymitis, orchitis, or Nausea and vomiting may or may not strangulated inguinal hernia. A defi- be present and can be dismissed as a nite diagnosis of strangulated hernia possible aid to a diagnosis, was made in over 50 per cent of the Swelling of the scrotal contents with cases where vomiting was present. marked oedema extending to the oppo- Etiology ^ite side of the scrotal partition is fairly lorsion may occur at any age but in constant. The shortening of the cord the majority of cases it occurs at the by the twist gives the scrotal contents age ot puberty. the appearance of being pulled up into Seventy cases have been reported on the groin. Tenderness is a most im- the right side as against 54 on the left, portant symptom but not as acute as in Ihe various authors agree that torsion the infectious processes occurring in is dependent upon two factors: this region. ~Z~T^ ^ , ^ ^ diagnosis is exceedingly difficult Read before the Tr.-State Medical Associa- and is very often not made until an ion of the Carolmas and Virginia, Norfolk, operation is performed. The condition Va., February 22-23, 1922. j^ frequently confused with strangulat- SOUTHERN MEDICINE AND SURGERY May, 1922. ed inguinal hernia or incarcerated omental hernia and they are excluded with great difficulty. In a differential diagnosis in this region we usually have to exclude an acute epididymitis because of the frequency of this condition. The Most Valuable Points of Differen- tiation 1st— Elevation of the scrotal contents as if it Vv'cie ,:ulled up into the inguinal region. 2nd — M a r k e d oedema extending across the septum, giving the appear- ance of encroaching upon the other tes- ticle. 3rd — Mild degree of tenderness as compared with acute infectious proc- esses of the scrotum. Treatment A few cases are on record where de- tersion has been successfully performed when seen within a few hours after on- set. If the testicle can be saved and the circulation is not permanently inter- fered with, orchidopexy can be done. Eversion of the tunica vaginalis is usually sufficient. In any case where gangrene, necrosis or any permanent circulatory obstruc- tion is met, removal of the testicle and as much of the cord as is indicated should be done. Case Reports Case No. 1 — J. M., age 19, a cavalry- man by occupation. Presented himself at the veneral wards of an army hospital giving the following history: The afternoon before, while on duty, he suddenly jumped from the ground astride his mount. A few hours after- wards he felt a pain in the right side of the scrotum which was followed by slight swelling. On admission there was general ma- laise. No nausea or vomiting. Temper- ature, pulse aiid respiration normal. The patient did not look sick. He strenuously denied having had gonorrb^«^a. svphilis or chancroid. The physical examination showed a well nourished and developed boy, nor-^ mal in every respect except for his lo- cal condition in the region of right groin and testicle. At the external urinary meatus there was a sticky, glairy mucous discharge from which smears were made. No cul- tures were made. The urine was clear except for a few shreds in the first glass. The prostate and vesicles were normal. Patient was put to bed, an ice cap applied locally, given a liquid diet, and carefully watched. Laboratory Findings — The urethral discharge was reported positive for gon- ococci. Urinalysis was negative. Lateral vi^iv shorcing twist of cord. Pre-operative Diagnosis — Gonorrho- eal epididymitis. Operation — Scrotal sac opened in the usual manner. The cord showed a twist of one-half turn with complete obstruc- tion to the circulation and gangrene of the testicle. Orchidectomy was per- formed. There was a complete and un- eventful recovery. Case No. 2— G. H. T., age 34. Clerk in clothing store. (Reported by cour- tesy of Dr. Brodie C. Nalle.) Family History — Father died at the age of 50 of typhoid fever. Mother died at the age of 61 of pneumonia. Four brothers are living and well. Two sis- May, 1922. ORIGINAL COMMUNICATIONS 223 ters are living and well. One brother and one sister died during infancy. There wa^ no history of tuberculosis, malignancy, epilepsy or insanity in fam- ily. Aniero posterior zici>.' sluncing hvist of cord' Past Medical History — Patient's gen- eral health has been excellent. He has never had an illness of sufficient grav- ity to confine him to bed and has never been in a hospital before. He gives no history of accident, injury or surgical operation. Past Veneral History — Patient had gonorrhoea eight years ago. He was successfully treated and has had no trouble in this connection since. He gives no history of abrasion or sore on penis. Present Illness — On the night of April 29, 1921, patient was seated on a couch when seized with a sudden sharp pain in the left testicle which was rather severe. During the night the pain moved up the left side of the ab- domen. He thought the trouble was due to constipation so took a cathartic with good results but was not relieved of the pain. The pain continually be- came more severe, and during the after- noon following the onset he noticed some swelling of the left testicle with slight tenderness. There was slight nausea but no vomiting Saturday after- noon (i. e., day following the onset). There was no history of chills or tem- perature. The day following the onset the patient consulted a physician, who thought his trouble was due to an epididymitis and gave him an ichthyol ointment, which did not give relief. This doctor continued to see him at intervals during the week following the onset of the trouble but the swelling and pain with tenderness seemed to be- come gradually worse. He had no trou- ble with constipation during this period. A week from the onset, the patient found temporary relief from cold appli- cations. The swelling and hardness of the left testicle continued and on Satur- day night, eight days from beginning of the trouble. Dr. Nalle saw him and ad- vised him to enter St. Peter's Hospital. I saw him the following day (ten days after onset) in consultation with Dr. Nalle. Physical Examination — Showed a well developed and well nourished man, apparently normal in every respect ex- cept his local condition in the left groin and left scrotal region. There was no spasm, rigidity or tenderness over any portion of the abdomen except in this region and there was no visible peris- talsis noted. Urethral discharge was absent. The prostate and vesicles were normal on rectal examination. In the left inguinal region and extending into the scrotum there was a hard mass con- nected with the testicle which was pull- ed high up in the scrotum. The mass could be traced into the inguinal canal but the outline of the testicle and epi- didymis was obscured. A tentative diagnosis of torsion of the spermatic cord with gangrene of testicle was made. Operation— At operation the cord was twisted by a rotation upon itself in a clockwise direction. The extent of the rotation was one-half turn. The testi- cle and that portion of the cord below the twist was gangrenous. Orchidec- tomy was done with complete and un- eventful recovery, the patient leaving the hospital within a week. 224 SOUTHERN MEDICINE AND SURGERY May, 1922. TRFATMPNT OF THRONTr "^^^"^ ^ discharging sinus which is sup- TREATMENT OF CHRONIC ^^.^^ ^^ ^ p^^j^^^ ^^ multiple pockets EMPYEMA* Qf pus in the pleural cavity, the size of By Frank S. Johns, M.D., F.A.C.S.. the cavitv, and the duration of the in- Richmond, Va. fection influencing the compressed lung T .■ .1^- ' T • u 4- 4- and the rigidity of the walls. In presenting this paper I wish to set before you the factors which I believe The most common causes of chronic are most important in the treatment of empyema are inadequate drainage, tu- chronic empvema. A study of the cases ^erculosis, foreign bodies, infection of that have come under my observation ^he ribs, broncho-pulmonary fistual due and the information from other sur- to too late drainage, pneumothorax due -eons, indicate that chronic empyema is ^o early open drainage, or a ruptured a rare condition if the acute disease has subpleural abscess resulting m a col- received proper treatment. ^^P^ed lung not yet fixed with adhesions, The fundamental principles laid down ^nd reinfections of the pleura . by Hippocrates in the fifth centuary B. The blood picture in these cases gen- C. substantially hold good today. If his erally shows a leucocyte count from 8,- cases remained ill for fifteen days they 000 to 12,000 with a secondary anemia, were examined for fluid. The operation The bacteriological study by Gordon" consisted of incision at the most de- in 1917 and 1918 shows that hemolytic pendent location, drainage and later ir- streptococci play a minor part in em- rigation. pyema which has developed into the For many centuries following, little chronic state. A typical bacterial pic- progress was made in operative and ture in the cases reported by Gordon diagnostic methods. In 1761 Auen- would be ; Strep, hemolyticus gradually brugger' introduced the art of percus- supplanted by a flora of secondary in- sion of the chest. This procedure was vaders, which show a gram negative not popularized for years to follow, bacillus broadly belonging to the Freid- Estlander (1879) and Schede^ (1890) lander group. In civil life, the primary described extensive rib resections for organism is the pneumococcus not in- chronic empyema, their mortality re- frequently complicated by streptococcus ported as 21.1. Delorme' in 1894 intro- and staphylococcus, duced a new train of thought in the I feel that the treatment of acute em- treatment, namely, obliteration of the pyema should be mentioned in this pa- cavity by decortication of the lung, per because I am convinced that failure Fowler' was the first to report cases by to treat the acute condition correctly is the Delorme method, and has therefore responsible for a majority of the received much of the credit. chronic cases. The work of Graham From the above we find that the re- and BelF is probably the most valuable corded treatment of chronic empyema contribution on this subject. They has varied through the ages from the showed that the so-called late operation conservative to the radical. Now, how- was the one of choice, that the chest ever, in the light of present day thought should not be opened until the media- and our increased familiarity with the stinum had become fixed and adhesions pathology of the disease, we are turn- had formed between the lung and the ing to the conservative again- chest wall. They concluded, therefore, The time at which an empyema that the creation of an open pneumo- should be called chronic is debatable. It thorax by the early operation not only varies with individual surgeons. I think limited the vital capacity of the affected the term chronic empyema usually lung but also had its effect on the re- • maining lung. *Read at the Norfolk meeting of the Tri- There are several operative proce- State Medical Association of the Carolinas and dures used for acute empyema, varying Virginia, February 22-23, 1922. according to the stage of the disease May, 1922. ORIGINAL COMMUNICATIONS 225 and condition of patient; namely, as- piration (therapeutic and diagnostic), intercostal drainage and resection of rib. Rib resection should always be done if frank pus is present and the patient's condition justifies it. Drainage at the most dependent point is imperative. Un- fortunately, every surgeon has resected a rib and found that there is a large pocket of pus below the opening. He trusts that this will drain adequately. When one encounters this state of af- fairs it is only fair to the patient to make a second opening at the lowest point so that the drainage will be com- plete. One will find that the first open- ing will heal promptly and that the extensive cases, one or more ribs should be resected, the parietal pleura which is always infected should be removed, and the cavity swabbed out with pure car- bolic acid and alcohol followed by nor- mal saline; closing the incision with a small drain in the most dependent point. I feel that if the cavity could be com- pletely sterilized (and I believe it can), drainage should be omitted. So far I have not had the courage to close the incision tight. The introduction of Dakin's Solution has considerably aided our preliminary treatment. These old empyema cavities are lined with a fibro-purulent coat which is very hard to detach. It has more dependent opening will save weeks in the hospital. If there are no contra- indications, Dakin's solution undoubted- ly is the antiseptic of choice. The im- portant principles in the treatment of acute empyema are, avoidance of open pneumothorax during the acute stage of active pneumonia, early sterilization and obliteration of the cavity and main- tenance of nutrition of the patient'. The surgical treatment of chronic empyema has changed considerably in the past few years. The extent of the treatment varies with the individual case. It has been shown that Beck's Paste will sterilize a cavity and result in complete healing. In tubercular cases this seems to be the most satisfactory course. In the more been shown that the intelligent use of Dakin's Solution comes nearer meeting this requirement than any other anti- septic. I believe that every case of chronic empyema should have a thor- ough treatment with this solution be- fore surgery is resorted to, not except- ing the cases of broncho-pulmonary fis- tula. Prior to this treatment, it is nec- essary to establish proper drainage (and remove an infected rib). Pulmonary decortication should be re- sorted to in those cases which have been routinely treated with Dakin's So- lution without result. It should be done under combined local and gas oxygen anesthesia. This operation has become more popular in recent years due to the work of Lilienthal and others. In view 226 SOUTHERN MEDICINE AND SURGERY May, 1922. of the fact that the mediastinum is densely fixed and of the abundance of pulmonary adhesions, the danger is no greater in this location than major sur- gery in other regions. The improved rib spreader has limited rib resection considerably. A satisfactory exposure is usually obtained without cutting the ribs, but if there is need of a greater opening resection posteriorly will give an extensive exposure. The parietal pleura is dissected back, all the pus and loose pieces of the in- filtrated walls are wiped away, the in- cision is continued into the visceral area of the membrane, care being taken not to wound the lung, although this is not a serious complication ; the incision gradually widens and an attempt should be made to find a line of cleavage be- tween the membrane and the lung tis- sue". If this does not give the desired expansion, multiple incisions should be made over the entire adherent field; followed by right angle incisions" to the first; giving a checker-board arrange- ment. This should be done with a great delicacy so that no serious injury is done to the lung proper. This proce- dure will result in further expansion of the lung, No° attempt should be made to peel the lung from the chest wall for two reasons: first, for fear hemorrhage will follow; and, second, lest it cause extension of infection. The incision should be closed in layers with insertion of drainage tubes followed in thirty-six hours with a limited amount of Dakin's Solution'. These cases should begin blowing exercises twenty-four hours af- ter operation, as this will aid greatly in the expansion of the lung. The results in these cases are very satisfactory. The obliteration of such cavities are due to the removal of the rigid wall of the sinus with the sur- rounding infected tissue, and the free- ing of the fixed lung. 1. Auenb rugger, L.: On Percussion of the Chest. 117-148 In: Camac, C. N. B.: Epoch- making Contributions to Medicine, Surgery and Allied Sciences. 2. Estlander, J. A.: Resection des cotes dans I'empyeme chronique. Rev.mens. de med. et de chir., 1879, iii, 157-170. Estlanger, J. A.: Encore quelques mots sur la resection des cotes dans I'empyeme chronique. Rev.mens. de med. et de chir., 1879, iii, 885-888. 3. Schede, M.: Die Behandlung der Empy- eme. Verhandl.d. ix Cong. f. Innere Med. Wiesbaden, 1890, ix, 41-141. Also (abstr.) Therap. Monatsch., Berlin, 1890, iv., 275-277. Also (abstr.) Allg. Wien. med. Ztg., 1890, XXXV, 258. 4. Delorme, E.: Nouveau traitement des empyemes chroniques. Gaz. d. hop., 1894, Ixvii. 94-96. 5. Fovvrler, G. R.: A Case of Thoracoplasty for the Removal of a arge Cicatricial Fibrous Growth from the Interior of the Chest, the Result of an Old Empyema. Med. Rec, 1893, xliv, 838-839. 6. Hedblom, Carl A.: Treatment of Chronic Empyema. Annals of Surg., Vol. LXXII, 1920. 7. Graham, E. A., and Bell, R. D.: Open Pneumothorax; Its Relation to the Treatment of Empyema. Am. Jour. Med. Sc, 1918, clvi, 839-871. 8. Graham, E. A.: Principles Involved in the Treatment of Empyema. Surg., Gynec. and Obstet., XXXI, 60, July 20th. 9. Lilienthal, H.: Thoracic Fistula and Chronic Empyema. Ann. of Surg., 70, 43, .July, 1919. 10. Ransohoff, J.: Discussion of the Pleura in the Treatment of Chronic Empyema. An- nals of Surgery, 1906, xliii, 502-511. Discussion. By Dr. S. S. Gale, Roanoke, Va. I was very glad to hear Dr. Johns say in his paper that the treatment of chronic empyema really begins with the May, 1922. SOUTHERN MEDICINE AND SURGERY 227 proper treatment of acute empyema. I the tube and the skin in order that the think as the treatment of acute empy- tube cannot be displaced. When the ema is perfected we will have to deal patient gets in bed connect this tube less and less with the treatment of the with a long tube that goes into a bottle chronic type. one-half to three-quarters full of some There are several different methods antiseptic fluid, and allow drainage to of surgical procedure in the treatment be continuous into this bottle, of acute empyema. I will not attempt In about twenty-four hours we begin to discuss all of the various plans of to Dakinize these patients every two treatment at this time but simply de- hours in the daytime and every three scribe the method of treatment which hours at night. We have had one case we have found very satisfactory during that got entirely well in two weeks. In the last twelve or eighteen months. the last month we have had four cases, We have been treating our cases by all of which were treated this way. One means of intercostal drainage and Da- of these cases, while not entirely well, kinizing the empyema cavity. In the was able to leave the hospital at the last ten or fifteen cases we have not re- end of eighteen or nineteen days. Pa- sected any ribs. We did it all through tient was under constant observation intercostal drainage. I think this until the wound was entirely healed and method, so far as I can recall, was first we were satisfied that there was no re- described by Dr. Mazingo, of Washing- accumulation of pus in the chest and ton, D. C, during the war, about 1918. the patient returned to work well. We Briefly, Mazingo's method was to use think by this method the period of con- intercostal drainage by means of intro- valescence has been very greatly short- ducing a catheter into the empyema cav- ened. We feel that it has really been a ity through a cannula at the most de- distinct advance in the treatment of pendent portion of the empyema cavity, these cases. We know that this is not care being taken not to permit any air new and that a great many surgeons to pass into the pleural cavity through are using this method and we simply the cannula. This catheter was then call attention to it because it seems to connected with a long rubber tube, the us the best. end of the tube being immersed in a In the treatment of chronic cases bottle half to three-quarters full of there is very little I could say more some antiseptic solution. In this way than the doctor has already brought out negative pressure was obtained and the in his paper. I think it is really very pus from the empyema cavity siphoned advantageous when possible to use the into the bottle. Of course, this opera- rib spreader instead of resecting the tion is usually done under local anesthe- ribs. sia. We have found from experience In regard to the splitting of the that as a rule we cannot get a large pleura, or stripping, we have found in enough catheter into the empyema cav- some of these cases that the pleura will ity through a cannula although within pull off from the lung very easily. In the last two weeks I have seen a can- these cases you can really strip the nula that has recently been made which pleura from the lung without injury to is as large as the index finger. In the the lung. However, in some other cases last three or four cases we have treated the pleura is very adherent due to a by this method we have used a rectal fibrosis of the pleura, the connective tube for drainage, making our opening tissue fibers having embedded them- through the pleural cavity under local ggi^es in the lung tissue. In these cases anesthesia, being very particular not to .^ ^^^,^ ^^^ ^^ ^^^^ ^^ ^^^. ^^^ ^^.^^'_ get any air mto the chest cavity, and , , mi ^^ insert our rectal tube into the empyema ^ned pleura. These are the cases m cavity, close the wound tight around the which the checkerboard incisions tube, usually taking one stitch through through the pleura would be indicated 228 SOUTHERN MEDICINE AND SURGERY May, 1922. and thus permit the lung to expand and frequently, only too frequently, cases of fill up the chest cavity. marked deformity of the chest follow- Dr. E. E. Watson, Salem, Va. ing empyema cases which I am sure I have had very little experience in could have been prevented had the sur- the ordinary empyemas, but I do, in S^^" ^^^^"^ ^he proper precautions as to tuberculosis work, not infrequently run carrying out such simple exercises as I across tuberculous empyema. If I have ^^^^ outlined, learned anything from this experience Dr. J. O. Boyd, Roanoke, Va. with such cases it has been not to drain i had the privilege of watching Mo- a tuberculous empyema. I think that zingo and Detrick try their methods out the treatment of choice in these cases in the army service. You have seen hia is to aspirate and replace the fluid with (Detrick's) curved trocar advertised in air; in other words, use artificial pneu- some of the journals. Many of the mothorax. In my experience drainage cases that they cured were cases where has always caused a permanent fistula, simple aspiration would relieve. Det- and the cases terminate fatally. We do rick got wonderful results, at first. At get occasional good results in these first they had one ward which increased cases by removal of the fluid and aspira- to two. The ones that went out with tion. Sometimes I have tried an injec- early treatment in acute cases, usually tion of a 2 per cent solution of formalin were carried out. The lungs were ex- in glycerine. panded, which was attempted by nega- It seems to me that in these chronic tive pressure with the tube put from cases of empyema we should be very below up over the rib, so he would have careful to exclude tuberculosis if we are a valve action and thus always have a going to do drainage. negative pressure. He used the Dakin Dr. H. P. Mauck, Richmond, Va. solution every four hours, injecting it I want to take up and discuss one of ^^^^ ^^^ ^uer syringe. He didn't get the results of chronic empyema that the his permanent cures surgeon is prone to neglect; the result- ^ Mozmgo was sent down to Camp Pike ant deformity of the chest and curva- ^^^^ WaHe^ Reed to try his method, ture of the spine that results. ^^ tried the same thing but didn t ad- , , ,, ^ ^ ^ , , , ^ , vise putting in his tubes immediately. I am glad that Dr. Johns brought out ^^ ^^^^ ^^^j^ ^^pj^^^^ ^^ ^^j.^^^ p^^g, m his paper two points, namely : that m ^^^^ ^^^ ^^^^ p^^ .^ ^^^^^ Mozingo's certain cases these cases can be cured ^^^^^^ differed, in that after four or by spreading the ribs, without taking ^^^ ^^^^ ^^ ^^^1^ ^^^ Formalin in glyc- theribout. That m Itself will mamtam ^^.^^ .^ ^^^^^ ^^ ^^^ j^^^.^ solution, the sympathy of the chest, to a very p.^^jj^^ ^^^^^ ^^.^^ ^^^ ^^^^ ^^^^ large extent. ^^^^ ^^^y. ^^ ^^^ resection. These two Secondly : That formerly we all hesi- ^^rds were kept full of empyema and tated to prevent the depression of the ^jth rib resection more cases were dis- chest wall, because we felt that the de- charged as cured, pression of the chest wall in itself was a factor in obliterating the cavity, but By Dr. Johns. Closing Discussion. by peeling off the thickened layer of i want to thank the gentlemen for pleura and by the checkerboard incis- the free discussion of this paper. In ions that tend to obliterate the cavity reference to Dr. Gale's discussion, there by the expansion of the lung. is one point which interests me very The derformity can be prevented by much, namely, intercostal drainage in following these cases with proper ex- acute cases ; of course, my paper is pri- ercises, blowing and respiratory exerr marily on the treatment of chronic em- cises, and by applying to these cases pyema. As stated in my paper, the proper supports which will prevent the treatment of the acute condition has a chest from going over to one side I very distinct bearing on the chronic May, 1922. ORIGINAL COMMUNICATIONS 229 cases. We all know that intercostal is practicable to attempt such an oper- drainage will give results in a limited ation on a very ill patient, therefore number of cases. I have seen cases simple aspiration in the early stages to cured by a simple aspiration, but it relieve respiratory distress is the pro- seems to me that a frank empyema cedure of choice doubfe'dlv'iM- trnn'" r""^ 'M' """ ™' ^"^^^^^" h^« ^^«" thoroughly doubtedly, It IS the operation of choice; worked out by Graham & Bell as I the important pomt in the cases is to have mentioned in my p^per. Thdr ex- 8-ive adequate drainage, and if possible, perimental work done at Hopkins on ^rf -n V T'Tu ^^r ^'' '-'■ ^«^- showed that an early operation le- tremely ill patients which will not stand suiting in an open pneumothorax car- resection, these patients should have ried a high mortality My beliefTs that intercosta drainage. To my mind, the these people are Lfferfng primarily and most of'lfn' ,^^^,^^^'^'"' "^^^ ' Pneumonia; that they s'hould be and most of them will, should have a aspirated for their respiratory embar- resection done at the most dependent rassment and operatioif should bT de- ^ • ferred until their primary disease Dr. Watson very aptly brought up (pneumonia) has subsided, and adhe- the question of not draining tuberculous sions have formed between the lung and empyema. I agree with him thorough- the parietal pleura and the mediastinum ly. I am glad to say that so far I have has become fixed, not had the misfortune to drain a tu- berculous case. Dr. Mauck has brought up the orthopedic side of this question. PERTINENT CONSIDERATIONS IN This IS a very important one, and his HYPFRTFN^inN* co-operation has been of great aid to H\I LKIENSION' me the treatment of these cases. The By w. w. Silvester, M.D., Norfolk, Va question that Dr. Geisinger has raised has been widely discussed during the medicine, as our studies penetrate years of the war; that is the question ^^eper into the problems of each indi- of early operation, for fear of not hav- ^'^^^^^^ branch or specialty, one fact ing the patient to operate on ; or to ^^^^^^^ ^"^ with ever increasing empha- wait until the primary condition' (pneu- '^^''' "^"^^ly, that medicine is a unit and monia) has subsided and adhesions had '"^^P^^'e of real division into special- formed between the visceral and parie- ^^^^' ^^^ superior man in the medicine tal pleura and fixation of the mediasti- °^ ^^^ ^"^"^^ ^^^" "^^ ^^ the great lab- num. oratory worker, or the man who is It was my good fortune to have ''"Tu" ^°' ^'l '^"^/'' '1 metabolism, charge of the empyema service in a "' ^^' "?"'^ gastro-enterologist, or base hospital durinf the years Tf 1917 T'h°^'''' "" T'^T 'l-^' 7^" 18-19. I did not follow the early opera- '^^ands pre-eminently above his confre- tion in any case-for two reasons first T' T his knowledge of diseases of the because the patients wle suffering p' ^''' T? .f^''^^^ 'l'*'"^' '' '^ '^' marilv from nno. r.^ ^""^ring pri- ju^gg, but the man who recognizes the cause onenirmo^^^^^^ '^""f' .^t ^^'' ^^'^' ^^e truths derived from all of itTeffpTnn ?hp^ !i i" T^l \^^ ^^''^ ««"^'^e« ^f «tudy and investiga- haVr TJe\Pett thf op" [^^"/l T' '' ^"^^T^^^ '' '.^^^"^^^^ Inno- ,.or>.^i,. .11 , °PP°^^\e to the human patient as a who e. In Z'hTela^sPd fr';."f '' f"'"^'. °^h^^ ^^«^^'«' the internist who appre- nt-^r'itTted'io^r^fthr ^r: ^i!:^^' ^^^^^^^'^^^ -^" ^^ ^^^ -- -^^ nnpl? n' "^'^'fl!"^ "^^lu^"* '^"'^"^ ^" *^-^ b^f«- *h^ Tri-State Medical Associa- open pneumothorax the results would tion of the Carolinas and Virginia, Norfolk nave been better, but I don't believe it Va., February 22-23, 1922. 230 SOUTHERN MEDICINE AND SURGERY May, 1922. regards his field of study in its intimate changes in the small arteries, the arte- relationship of the body as a whole. rioles, scattered throughout the body, How interesting and how wonderful and that while it is often combined with the unfolding when one can see rela- the conditions in the larger arteries, tionships in all the branches of this which we term arteriosclerosis, it is not wonderful science. A fact is worth lit- caused by such arteriosclerosis. With- tle unless it can be applied ; and it can- out question, we find hypertension in not be applied unless the one who patients in whom there is no demon- knows the fact has vision enough to see strable arteriosclerosis and arterioscler- when it fits in. osis of marked degree occurs with nor- Each day many relationships which mal blood pressure, should be obvious to the clinician are What is the cause of these changes facing him, but are unrecognized be- in the arterioles? By many it is stated cause of his lack of imagination. He that nephritis is the cause of hyper- fails to connect the cause and effect be- tension and that consequently, finding cause he fails to recognize the instru- a high blood pressure justifies the diag- ment through which the cause operates, nosis of nephritis, even though there is Briefly, I will discuss the general re- no other evidence of renal disturbance, lationship between hypertension, myo- We now know that very often we find carditis and nephritis and follow with a hypertension in patients in whom renal short discussion of treatment of hyper- function, tested by any method, is prac- tension. tically normal and that in hypertensive Often you will find cases that will cases, autopsy in some instances shows justify the diagnosis of but one of this only minimal lesions in the kidney. In triad, at other times two, or even three other words, we have evidence that ne- of them ; that is, there are some cases phritis is not a constant cause of hyper- in which you could demonstrate only a tension. Infection has been advanced high blood pressure without evidence of as an important cause of hypertension, cardiac or renal damage, while there in the sense that it has led to the vas- are other cases in which without a high cular lesions. We do know that many blood pressure or abnormal renal lesion, infections cause vascular lesions, de- the heart was enlarged and improperly monstrable under the microscope and functioning. In yet other cases normal they very probably may lead to per- blood pressure and a properly function- sisting vascular changes, causing hy- ing heart muscle, but poor renal func- pertension. Anyhow, there is a grow- tion. Much more commonly the find- ing belief that infection plays a large ings indicative of one of these groups Part in causing hypertension, were combined with those of another or The proportion of patients with hy- there was a combination of all three. pertension who have positive Wasser- Now, if you will think of the progres- n^^ann reactions is relatively very small, sion of events in any one of these cases, and anti-syphilitic treatment rarely hen- you will remember that in some, at first ^'^ts hypertension. there was hypertension, that later the Some endocrine disturbances are as- heart enlarged, that somewhat later sociated with hypertension, but that poor renal function appeared, and finally such a cause is at all general seems very a decompensated heart was combined improbable. Other causes may be as- with a picture of uremia. In other cases signed in a similar way. Hypertension a combination of two but not of all very likely is, in a sense, of the nature three conditions appeared. The occur- of a symptom and not a disease, an rence of these combinations suggests a expression of a disturbance that, like close interdependence of these processes fever, might have many causes. As to in their cause and their progression. the mechanism, it se«ms pretty certain "At present the prevailing view is that it is caused by a disturbance in that hypertension is dependent upon the small blood vessels, arterioles and May, 1922. ORIGINAL COMMUNICATIONS 231 rimilarities of the body. The similari- blood pressure cuccumb within three ties brought out justify us in grouping years of the time they come under ob- hypertension, nephritis and myocarditis servation. together. We are not justified in claim- 4, The chief causes of death in cases ing that there is any constant sequence of high-blood pressure are cardiac fail- in these processes, or that in any given ure and cerebral hemorrhage, case, at any period of time all three will 5. After the age of forty the percent- be present. age of mortality in patients with hy- There is much evidence to show that pertension increases with each decade, a very close relationship exists between 6. The height of the blood pressure, what we term hypertension, myocard- per se, whether the systolic or the dias- itis and nephritis and that a better un- tolic pressure is considered, bears no derstanding of these processes is ob- definite relationship to prognosis. The tained by considering their resem- most important factor in determining blances, rather than their differences, the prognosis is the underlying cause of whether we are studying their causes, the high blood pressure, their manifestations or their manage- Recently, another cause for hyper- ment. tension has been brought out, i. e., from "In discussing the treatment of any a disturbed salt metabolism and can be condition, it is well to consider carefully satisfactorily treated by eliminating what we hope to do; what it is pDssible «alt from the diet. There are many who to do, how we can do it and in how far do not hold to this view. Allen asserts the disease can be influenced. It may that in numbers of instances the salt be that the hypertension (or nephritis) restriction where indicated is by no can be terminated and yet extensive means carried as far as it should be. tissue changes remain. True, these In American literature, particularly represent, in some part, the process of up to 1919-1920, salt and fluid restric- healing, and to this extent are to be tion in hypertension is mentioned cas- desired ; yet we do not have a result ually and incompletely, if at all, and with complete restoration to normal. the protein intoxication theory is un- An individual may have the patholog- doubtedly the dominant one. ical changes and yet be in perfect Treatment consists chiefly in low pro- health, without any clinical signs of tein diets, the elimination of supposed hypertension. toxins, or the artificial reduction of In the study of 160 cases of high pressure by drugs, bleeding, electricity blood pressure from a prognastic stand- and the like. Mental and bodily rest is point, Piersol drew the following con- advised to a degree which largely ter- clusions: minates usefulness in life, and many 1. Chronic renal disease is chiefly re- conservative practitioners refrain from sponsible for hypertension in men, any serious attempt to reduce the pres- whereas in women hypertension is more sure, and devote themselves to keeping often the result of some primary vas- the patient as comfortable as possible, cular disturbance. The frequent occur- with resignation as to the results, rence of climateric hypertension largely There are various reasons for this accounts for this difference. confusion and pessimism according to 2. In cases of persistent hypertension Allen. In certain instances the cases the etilogy of the high blood pressure are not well chosen and the salt restric- bears a definite relationship to the prog- tion inadequate. Whether or not pro- nosis. The mortality is greatest in tein has any influence on blood pres- those cases of hypertension that are due sure, it is impossible to accept Ambard's to chronic nephritis. Menopausal hy- assertion that it is harmless in nephrit- pertension is conspicuously benign. is. Ambard considers fluid restriction 3. About 28 per cent of the chronic unnecessary, and in adopting milk diet nephritics that exhibit marked high he comes back to the identical therapeu- 232 SOUTHERN MEDICINE AND SURGERY May, 1922. tic program used by the followers of lieve conscientiously that strict absti- the intoxication hypothesis. nence from salt has been maintained, The fluid restriction of Laufer who when analysis will show the blood chlo- accepts von Noorden's limit of a liter a rides undiminished and an output of day without reckoning the important from 5 to 10 grams in the 24 hour additional quantities contained in the urine. Such analyses are important for food, is too lax for the worst cases; controlling the treatment and no pres- likewise a much more strict exclusion sure is rightly called irreducible unless of salt than represented by milk diet is the daily chloride excretion has been essential for results in really severe reduced to practically zero, cases. 2. A certain amount of salt is consid- These inaccuracies are responsible ered indispensible. As worked out in for an unnecessarily high percentage of the normal individual, about two grams, cases of absolutely or relatively irre- but the limits for nephritics have never ducible hypertension in various records, been determined. With certain nephrit- and also for the unnecessarily frequent ics, especially those with nitrogen re- and early deaths from apoplexy, cardiac tention, there may be danger of with- failure, pulmonary edema and convul- drawing salt, for they seem to need salt sions. For the same reason there have for its diuretic action to ward off ure- been no differences in therapeutic re- mia. The salt intake must be worked suits sufficiently marked to establish out for the individual, any one theory to the satisfaction of Reduction of the blood pressure all parties. nearly or completely to normal, may In the cases of pure hypertension, the still leave the patient an invalid, either kidney retains the power to concentrate, from weakness due to the strict salt and both the blood urea and the urea privation, which is necessary to hold function according to the Ambard prin- down the pressure, or still worse, if salt ciple, may be fully normal. But the is given to allow the pressure to go up. chloride threshold, whether determined The greatest defect of the French mathematically or by salt privation, is work is the disposition of those authors high and these patients purchase their to treat the entire question as a mere apparent efficiency of salt excretion at mechanical matter of salt retention, the price of abnormally high blood salt The mechanisms of hypertension re- and blood pressure. Extraordinary main largely unsolved and the funda- strictness of salt-free diet may be nee- mental condition thus baffles both re- essary to control these. While protein search and treatment, and water create no symptoms, on gen- gy f^r the best and easiest results eral principles they should be limited to ^re obtainable in the earliest cases, some extent. when the hypertension is intermittent In the hypertension cases with kid- rather than continuous. Early diagno- ney impairment, the degree of impair- sis is, therefore, important, ment in the nitrogen economy calls for ^ jg not true that any one method corresponding restriction of the protein ^f treatment is supreme for all cases and influences the prognosis. But the ^ut merely the best for a given case. I hypertension is affected only through ^Q^;^l^ have you believe that I am op- the salt and water functions. timistic about the treatment of hyper- In treatment, certain precautions or tension. Not all cases can be helped, limitations should be mentioned with ^^t many cases can be greatly benefited regard to the practical application in ^^ intensive and prolonged treatment treatment: „ ,, , . * ,• ^ 1 • L. • ui , . of the proper sort. 1. A diet which is reasonably satis- ,,, , , ,. , ,, fying and at the same time sufficiently We have at our disposal the means poor in salt is not so easy to arrange, with which to help many cases of hy- At times both physician and patient be- pertension. Many of these cases are ^^y- ^'^22 SOUTHERN MEDICINE AND SURGERY 233 TZfel7LiT^'"" ^'''"'' '^ ^"'^'- '"^"" ""^^""^ °^ ^^^* '^^y should take, quate handling. nine out of every ten will say, "But loday, the medical profession stands. Doctor, I do love my salt." It is char- as it were, at the bar of public opinion, acteristic of the condition that they are being judged. as to the service it is ren- heavy salt eaters, as well as, very fre- dering. Not able to see deeply, the pub- Quently, heavy protein eaters.' You can- he can but form its opinion from out- not get the salt intake down lower than ward appeararc-s ; hence it is quite nat- two grams in twenty-four hours. That ural that it should be impressed by an is the minimum to be sough^. for occasional cure achieved by a charlatan The average protein intake for the or seme member of an unskilled cult, day is 100 to 150 grams. If you gel And yet it must be admitted that to much below 75 or 60 grams the patien nX'fr fr '"'"'^ '"^'"'^ '' ^'^ "^'^ ^"^^^' ^-- Pr«t-- deficiency In public has at times some justification, my experience the most satisfactory rP^ Jn. h? " ""Tr r' "^"' '^^'' ^^ "^''^'^ ^' '^ ^"t down the salt to nearly le^sonably expected of us. minimum, and the protein intake to Ihe lay mind may be asking too around 60 grams. eTerv m "hn7 if" ''■ ^T^.^" ^ '"'' ^'' ^" *^^ ^''''^^' '^'^ «f "^P^^itis and ever.v ill, but it is justified in insisting of hypertension and arteriosclerosis the on a correct or accurate diagnosis in secret of the cure will probably be found ^^""^ ^^^^""^ to be in early recognition. References I have seen a few cases of early hy- Pcnna. Med. .Journal, January, 1922— Solo- pertension in which I felt I wa-^ doinp- mon, Neurosyphilis. good. For instance, a bov of 25, with Penna. Med. Journal. January, 1922— Vis- blood pressure of 138, and a very slight ceral Syphilis, McCrae. trace of alubumin in the urine. He had Riesnian — Abdominal Manifestations of one apical abscess which was treated by Thoracic Diseases, Medical Clinics of North extraction of the tooth. This was eight Amer.ca. Nov., 1921. months ago. His symptoms have clear- Medical Clinics of N. America, November, ed up, but he still has a little albumin i92i-p,ersol. Factors in Persistent High in the urine. His blood pressure is ten Blood Pressure. points lower. Here is perhaps a chance Henry A. Chnstian-Ill. Medical Journal, for CUre. The time to look for the fo- December, 1921. cal infection, and to start the dietary Allen, Frederick M.-Arterial Hypertension, treatment, to be most effective is in Journal A. M. A.. March 6. 1920. the earlier stages, such as in this case Pottenper, Francis Marion Symptoms of ^ „, „, ^., , _ Visceral Disease. ^^- "'• W. Silvester Closes Discussion of His Paper. Discussion. t „.^^i. + i • , , ^ 1 want to emphasize what Dr. Dr. W. T. Vaughan, Richmond, Va. Vaughan has said in regard to cutting Rnfh Dr Q.-i,r.of J T^ XT , ^^^^ ^^'^"^ ^^^ ^i^t. You have to give .tri H ^'^^^ff! ^"d Dr. Nelson them a salt free butter. You will per- t Te"^t"sserthat'' th'" T' .'i'' ^^°"^"-^' ^^^'^ '^ ^^- instructions toThe T^eit if no Lil f ' f '^^^ '"^'^'- '''^ ""d ''' *^^t the instructions are what thev have ?«f%v' • ''^'l^^"^ '^''''^ °"t' «^ >^°^ ^"^ "«t ^«t what is Tf the snl p^tTh.? f ' :? ^ P^^'' ^^d^^^d- You can cut down your pro- 01 tne subject that is frequently com ng f^,-„ +^ „u <. ca . . into discussion. ^^^^ *^ ^^°"t ^^ grams as a minimum. If. when you are talking with your ^^^Y can Tiave a fairly high caloric diet, chronic nephritic or hypertension pa- ^°" ^^^^ ^^^ protein down, and the tients, after you have discussed cutting ^"^'^ intake low. They should have a down the protein intake, you now touch salt free bread. The essential thingls on the subject of salt, and describe the to keep the salt intake low 234 ORIGINAL COMMUNICATIONS May, 1922. NEOPLASMATA OF THE CLITORIS* By Frank D. Worthington, Charlotte, N. C. A recent case of carcinoma of the clitoris furnished me the stimulus to review the literature on new growths of that organ, and although I was aware that the condition was rare, still it was only after considerable vain effort to obtain information on the subject that I realized how genuinely unusual these neoplasms are. In 1917, Battey, of Augusta, review- ed this subject and at that time could collect but twenty-three reported cases in the preceding twelve years. Since that time there has been nothing pub- lished in the better class of medical journals. Undoubtedly there have been a number of unreported cases but the rarity should be sufficient grounds for the report of this one. New growths of the clitoris may be divided into the benign and malignant type. Of the former there are three: (1) Lipoma. (2) Simple cyst. (3) Naevus. These tumors naturally may be dealt with in a conservative manner. The second class includes sarcomata and carcinomata. Sarcoma is almost unheard of. Kelly, of Baltimore, re- ports one case operated upon at the Hopkins clinic. The patient after dis- charge from the hospital one week after operation was never followed so the ul- timate outcome is only conjecture. Carcinoma of the cliteris is more common but this is also rare. Chronic ir- ritation seems to be a contributing fac- tor and multiparae are more often af- fected than nultiparae. The disease as a rule appears in the latter half of the life cycle and in that way conforms to the habits of all carcinomata. However, younger women may be sufferers and the prognosis is relatively bad in these cases. In fact, the prognosis is bad even *Read before the Tri-State Medical Associa- tion of the Carolinas and Virginia, Norfolk, Va., February 22-23, 1922. in the elder patients and is undoubtedly influenced by the abundant lymphatic drainage of the affected part and the early metastasis to the pelvic lymp- nodes. Dissection and injection of the lymphatics of the vulva and clitoris by Basset, reported in Review of Surgery, Paris, 1912, shows that innumerable microscopic lymph vessels combine to form larger trunks which empty into the inguinal lymph-nodes. Those run- ning from the glans of the clitoris an- astomose freely, two collecting trunks then radiating to both right and left, one trunk traversing the inguinal canal and one the femoral canal eventually emptying into the glands inside the pel- vis. The anastamosis above the pubis is of importance in operative technique and the early metastasis to inaccessible pelvic glands is an important contribut- ing factor in making the prognosis so grave. The symptom first complained of is usually itching, which is later explained by the appearance of a tumor or an ulcerated surface. Pain is not a com- mon symptom, although present in my own case. This may be accounted for by the variety of treatment which she had received before coming into our hands. The treatment at present consists of wide excision of the tumor with the lymphatic gland en bloc. Extending from about the anterior superior spine on either side two radiating incisions are made, one going well above the pu- bis and joining the similar incision from the opposite side and the second radiat- ing inward and downward outside the clitoris, including the vulva and joining the incision from the opposite side just above the urethral orifice. The lym- phatic glands of both groins are dis- sected out clearly by sharp dissection and the dissection is carried to the mid- line and includes the supra-pubic fat and glandular tissue. The entire mass outlined by the primary incision is then stripped from the pubis and the tumor with glands freed en bloc. Undermin- ing may be necessary for closure and the lower ends of the incisions running May, 1922. SOUTHERN MEDICINE AND SURGERY laterally should be drained. The above is the procedure we car- ried out in our case which I shall now report. Mrs. M. L., aged 29. Comp. — Tumor above urethra. Essential Past History — General good health. Marital— 13 years. H. 1 and w. 3, C. 1 and w. 1 miscarriage. Menstrual — Periods always irregular, varying from four weeks to several months. Has menstruated only four or five times during last nine years, but this may be accounted for by the fact that she has nursed all babies for about two years; is nursing baby at present. Periods when present are normal. P. I. — Began immediately after birth of youngest child 18 months ago. First noticed a sore, itching spot just above the urethral orifice. No actual pain. This was treated with local applications but then a growth was noticed which about six months ago had reached the size of the end of a finger. The patient was told she had a caruncle ; a partial local excision was done. This did not produce a cure and the tumor increased in size gradually. Four weeks ago she had several applications of radium to tumor. Following this there was some sloughing with ulceration but this has disappeared. Since that time the tumor has increased in size and has been very painful. Physical Examination — Except for the fact that the patient is anemic and generally undernourished the important findings in the physical examination are entirely local. In the region usually occupied by the clitoris there is a tumor about 21/2 cm. long and 1 cm. wide. It is dark red in color and appears eroded and ulcerated, the edges are irregular. It is exquis- itely tender to touch. The lower border is about 2 cm. above the urethral ori- fice. There is a chain of hard glands in the right inguinal region and two palp- able glands on the left side. On pelvic examination the anterior vagfinal wall, the fundus and adnexae are perfectly normal. Wassermann — Negative. Diagnosis — Carcinoma of clitoris. Treatment— Dec. 30, 1921. Operation under ether anesthesia. The tumor with the inguinal glands was removed as out- lined above. Pathological Diagnosis — Squamous celled epithelioma showing vci-y definite invasions of the surrounding tissues. There is no evidence of any metastasis in any of the lymph glands. Post-operative Course — Aside from slight infection with a resulting slough of the terminal edge of the abdominal skin flap the patient had an uneventful convalescence. The perineal portion healed well and the patient's general condition markedly improved. At the present time the wound is entirely heal- ed and there is no evidence of any re- currence of metastasis. THE PHILOSOPHY OF GROUP OR RATHER CO-OPERATIVE PRACTICE* By J. E. Rawles, M.D., Suffolk, Va. The world began as a unit with the Creator. This unifying force has been on a conquering mission since creation. This eternal unit will go on conquer- ing until the end of creation, regardless of opposition. Yes, a circling journey or mission from one to one — from unit to unit. History emphasizes this truth. This unifying spirit is an instinct of the hu- man race whether in savagery or in civilization. In primeval savagery we find the fam- ily unit held together by physical force. In the most recent civilization we find myriads of families as a unit and held together by the spirit of unity and love in a state of united democ- racy. Later with the savages we find tribe units with their chiefs held together by physical force. '■'Read before the Tri-State Medical Associa- tion of the Carolinas and Virginia, Norfolk, Va., February 22-23, 1922. 236 SOUTHERN MEDICINE AND SURGERY May, 1922. As the human race become less sav- vice and life, while the latter bespeaks age we had monarchial units with their retrogression, injury and suicide. Kings and held together by main and The co-operative or living spirit has muscle. been grasped not only by the nations In modern times, as the human race as a basis of government but by the begins to see, she views life from a commercial world. different angle, she is beginning to have At first the people could not under- a vision of this above unity, as applied stand this in the commercial world, and to all mankind, in a world democracy, thus the newspaper and magazines were governed and held together by a spirit filled with long articles on "trusts, mo- of brotherly love. nopolies and combines." The newspa- So today our newspapers are full of pers howled for awhile, and legislature the League of Nations, Association of got busy, but the true co-operative busi- Nations, and Disarmaments, which are ness enterprises marched on in progress but echoes of the conquering spirit of serving the human race — giving better unity that began with creation. Re- goods for less money. Will not men- member from unity to unity. tion the success of any of these large This conquering spirit of unity has corporations ( or better co-operations) had no easv journey. ^'-^^ ^''^^ ^^^ your mind recall and enum- The great libraries of the world will erate. At first the majority of the tell you of the red and rugged way. business world had not advanced to the "Wars and rumors of wars" is the story, stage of a few, and this majority but still triumphant on the trail. thought these few were enemies, and History on all of her pages only be- they were. Enemies not to the individ- speak of two forces at work, namely: "^Is as such, but to their method of A unifying or centralizing force and' a business, namely, competition. In other disorganizing force. words it was a conflict between co- These two forces have characterized operation and competition. Their rec- all wars and human conflicts of the ords and results so far as success in past. the business world stand for them- op] YT-po In our own history we do see this ' truth emphasized. This unifying or co-operative spirit The Civil War was a war of what? bas been caught here and there by all A conflict between this unifying force vocations and professions, to unite the States, and the force of In the church world we see it shin- disintegration to maintain independent ing out in the so-called "Federation States. The united effort won because of Churches," and other eflForts at it was a step further in the right direc- churches unification. This unifying or tion in the progress of the human race, co-operative spirit reached the medical Again what do we find in the World profession some years ago. War? Only the same two forces at Its initiation has been duly accredited work. We find a conflict between this to a great American clinic. Still the spirit of unification or centralization in organizers of this clinic claim no origi- the form of the Allies and the spirit of nality. This is true only in part, as disorganization or disintegration in the every great step forward is an expres- form of Hunism. sion of a public sentiment or demand. These two forces of history are char- For years after this unifying or co- acterized, the one by co-operation, and operative clinic was organized, it was the other competition. the talk of the medical profession and This centralizing spirit of unity has is now. Some claimed them to be as a basic foundation of co-operation, quacks, while others said they were This spirit of disentegration has as a forming a trust and doing wholesale basic foundation of competition. surgery. Other physicians more char- The former bespeaks progress, ser- itable explained their success on the May. 1922. ORIGINAL COMMUNICATIONS 237 ground of thorough western business ure and a farce. Some would have you methods— meaning by this shrewdness to beheve that this co-operative medi- m the commercial sense. cine is only intended for, and can serve The trouble was not with the clinic the physician in some great organized but with the profession at large. The college group in a city, or some great profession had not progressed or ad- clinic. This is false and misleading, vanced to the extent of appreciating the This spirit of co-operation for better underlying principle that were giving service works well with the country them success. This principle was this physician. unifying force of co-operation for bet- Doctor No. 1 and Doctor No 2 are ter service to the patient. The profes- country physicians and neighbors They sion was blmd and was still using her resolve to unify or co-operate their ef- forces in the suicidal spirit of compe- forts that they may give better service ^'^'^"- to their patients. They meet at ap- The eyes of the profession have be- Pointed times, and discuss the health gun to open to this unifying or co-oper- o^" the community, and report to each ative spirit, and to throw off the shack- other interesting cases. Call each other les of ignorant professional competition, in consultation when necessary. Occa- So here and there we see physicians sionally they take it by turns to go on getting together in a co-operative spirit a vacation and leave their practice in for better service, and the medical jour- the other's care while absent. On his nals are filled with articles advising the return his practice to be handed over best methods for organization. Feeling to him. During this vacation the doctor that something new has been discov- should spend a great portion of his time ered — a truth as old as creation. in visiting clinics and taking post-grad- We must have a true conception of uatework. Then on his return he can the basic foundation upon which such P^i^'e his brother physicians the infor- a medical organization should be built, mation received while away. Thus both As the unit one is to the multiplication will gain knowledge that they may ren- table, so is this unifying co-operative f'e'' better service to the patient and spirit on the part of each physician es- community. If wisdom demands, a sential to a successful medical organi- third, fourth or fifth physician may be zation for better service to the patient, added as long as they are converts to So the unifying co-operative spirit is this co-operative spirit, the essential unit. Yes, seek ye first Selfishness and competition have no co-operation with honest effort, and place in such an organization. Later these other things will be added unto the members of such an organization you. Just how we do not know. can devote their extra time studying in One of the most successful co-opera- some special line of work of which they tive organizations testify that their are especiallv interested or inclined In course has been a zig-zag one— first this this way the field of work can be more way and that way— but keeping at or less covered with greater efficiency, heart at all times the co-operative spirit The details will work out themselves if for better service to the patient. They each physician of such an organization were being led to their goal. is a thorough convert to this unifying No physician or set of physicians has or co-operative spirit for better service. a monopoly on this unifying or co-oper- The financial side of the work has ative spirit. This unifying or co-oper- not been mentioned. It is omitted pur- ative spirit for better service is appli- posely. It will fall in line in proportion cable to all physicians. It can serve the to service rendered, country cross-road physician in his Remember this, in the spirit of the work, as well as it does the physician moral law, we must lose our life in Sho^Zl TT'\,!' /'^^?^'^^ clinic- this unifying and co-operative spirit for Should It not do this it would be a fail- service to find our life-our true self 238 SOUTHERN MEDICINE AND SURGERY May, 1922. We have reached our zenith of great- ness and glory when we have lost our- selves in service for others. ACUTE PERFORATION OF DUODENAL ULCER* By Geo. H. Bunch, M.D., Columbia, S. C. Of abdominal emergencies, not one is more classical in beginning and in course than is the acute perforation of duodenal ulcer. The clinical picture is so striking that when once seen it is never forgotten. If one has in mind the possibility of the condition, its recogni- tion, when the case is seen early, is usually unmistakable. There is sudden, agonizing, uncontrollable pain in the epigastrium and right hypochondrium. The pain is continuous and unabating. Morphine in maximum doses does not control it. We have seen a grain given in six hours fail to give relief. The patient does not toss about as in hepa- tic or renal colic, but lies prostrated on his back wherever he happens to be when the perforation occurs. He is so overwhelmed by the pain that he is unable to move. There may be nausea, but this is not striking and is seldom accompanied by vomiting. Pain is the predominant symptom. Physical exam- ination shows the abdominal muscles on defense — contracted to protect and shield the underlying pathology — in a state of board-like rigidity. In no other lesion is the rigidity so marked and so constant. Although the muscles are un- yielding to pressure, the patient cries out at the suggestion of palpation. When seen early, there is no distention. Typmanites commences later, with peri- tonitis. The pulse is of good quality, with but little increase in rate. Al- though so acutely ill, the patient may have a pulse of eighty. A rapid weak pulse early after perforation is sugges- tive of hemorrhage. Later it is a sign *Read before the Norfolk meeting of the Tri-State Medical Association, February 22-23, 1922. of peritonitis and sepsis. There is neither leucocytosis nor fever. The tem- perature may be sub-normal. Duodenal ulcer occurs four times in men to once in women. Beginning usually in young adults, when untreat- ed, it tends towards a characteristic chronicity of indigestion and hunger pain with more or less regular inter- missions and exaccerbations. A man that for years has had spells of indi- gestion and pain in the epigastrium, coming on two or three hours after eat- ing and relieved by eating or by taking soda, has ulcer. A typical history is diagnostic. The test meal and the X- ray are confirmatory. Whether it be acute or chronic, any ulcer may perforate, and perforation may be the first indication of acute ulcer. The sudden prostration of a vig- orous young man, who may not have had a sick day in his life, is the story in perhaps one-third of the cases. Even the chronic cases, unless there be ob- struction of the pylorus by cicatricial contraction, have good appetites, and show no great loss of weight. We think every acute duodenal ulcer should be treated medically as soon as recognized. Medical treatment and diet- ing will undoubtedly cure many of them. In chronic ulcer, with its con- stant cycle of intermission and recur- rence, medical treatment cannot hope to effect a cure. When medical treat- ment has been tried and has failed to cure, surgery is strongly indicated. Deaver says, "There can be no question that ulcer of the duodenum is a graver disease than is gastric ulcer ; its greater liability to fatal hemorrhage and to per- forating make a sudden death probable in about one-half of the cases, unless some treatment can be applied which will not only relieve the symptoms, but entirely cure the disease." If patients were told the danger of delay, there would be fewer chronic ulcers, for they would be operated upon and cured early. The treatment of perforated duodenal ulcer is immediate operation, the sooner the better. The contents of the upper alimentary tract are relatively sterile, May, 1922. ORIGINAL COMMUNICATIONS 239 but peritoneal contamination begins gut was with difficulty packed away with the perforation and continues until from the operative field. Two non-in- it is closed. Every hour counts. Under durated ulcers, both perforated, were a general anaesthetic, the perforation is found one-half inch apart on the an- found and infolded. If there is pyloric terior duodenal wall, just beyond the obstruction from the ulcer or from the pylorus. Without cauterization, both infolding of the ulcer, posterior gastro- ulcers were infolded and reinforced with enterostomy is done. Some operators omentum. One cigarette drain was do gastro-enterostomy after every per- placed near the operative field and an- foration, even though there be no ob- other in the pelvis. The patient was struction, if the condition of the patient very weak. The distention gradually permits. Most surgeons do not drain disappeared, but the wound became in- the abdomen after a duodenal perfora- fected, and there was always some fe- tion. ver. The bowels moved regularly. He Our records show that we have oper- took nourishment as it wa^ given him. ated on seven cases of acute perfora- We considered him convalescent. On tion in duodenal ulcer, with one death, the fifteenth day he had a sudden, se- Although nearly one-half of our work vere paroxysm of epigastric pain, had is done upon negroes, these perforations a chill, broke into a cold sweat, and were all in active working white men. soon died. Autopsy showed the perfor- Their ages were eighteen, twenty, ations closed at the operation holding twenty-four, twenty-five, thirty-one,' perfectly. Another ulcer, about one and thirty-seven and forty-seven years. The one-half inch distal to the first two, had youngest three had acute ulcer. They perforated. We believe it formed and had never previously had pain or diges- perforated since the operation, tive disturbance. The twenty-five-year- On March 31, 1920, we operated upon old man had indigestion and heart burn an emaciated man of thirty-seven, with for the first time about two weeks be- a blood pressure of 98-68 and a hemo- fore perforation. The oldest three pa- globin of 50 per cent. He had a history tients gave an ulcer history varying of chronic indigestion and pain since from two to twenty years. Our first boyhood. On March 22nd, he had se- case was an acute ulcer of the anterior vere pain in his abdomen, a chill, nau- wall, which we infolded without cau- sea and cold sweating. His next stool terization or anastomosis. He was done contained much dark, tarry blood. The in 1916, twelve hours after perforation, epigastric pain continued for three days, and was well when last heard from in He was exceedingly weak. Every con- 1918. sequent stool contained blood. He was In 1920, we operated on two cases of admitted to the hospital on March 29th, perforation in acute ulcer, twelve and with a hemoglobin of twenty per cent, fourteen hours after perforation. After and a citrate transfusion of 800 c.c. was pushing a red hot cautery point through ^iven next day. At operation, in try- the perforations, the ulcers were in- i"g to get an exposure, the duodenum folded. Gastro-enterostomy was not ^as torn through a recently perforated, done. They are both well and free from walled off annular ulcer and almost sep- symptoms today. In 1920, eighteen arated from its attachment to the stom- hours after perforation, we operated ^ch. The perforation must have oc- upon a very toxic case, with diffuse per- curred on March 22nd, with profuse itonitis, with the abdomen greatly dis- bleeding into the mtestme, an unusual tended, blood pressure 115-75, leuco- complication in our experience. The cvtes 9000, temperature 100, pulse 108, "^cer was excised and pylorectomy done, respiration 64. We feared to give a communication being re-established by general anaesthetic and under one-half posterior gastro-enterostomy. He had per cent novocain infiltration, the in- a smooth convalescence and is now in cision was made and the distended small good health. 2W SOUTHERN MEDICINE AND SURGERY May, 1922. In December, 1921, we operated upon We infold the gut along the longitudinal a man of thirty-one, and in January, axis. Beginning about one and one- 1922, upon a man of forty-seven, who half inches beyond the ulcer, the inter- had long ulcer histories. They were rupted mattress sutures of fine pachen- both operated upon within two hours of stecher are all put in before being tied, perforation, though neither was in the The end sutures are carefully tightened hospital at the time of perforation, and tied first, the ends being left long They both had large, indurated ulcers for traction. The sutures over the ul- extending well beyond the pylorus and eer are tied last and the friable tissue into the stomach, causing obstruction through which they are placed is in this of the pylorus, one having vomited all way relieved of all possible tension, food for two weeks before the perfora- When this row of sutures is completed, tion. In both cases the ulcers were it is covered by a second row and the cauterized and infolded and gastro-en- whole ulcer area reinforced by gastro- terostomy done. They are both appar- hepatic or gastro-colic omentum sutur- ently well. ed over it. This takes time, but it is Where perforation is suspected, we necessary to insure a safe closure, think it well to give, as suggested by Before closing the wound, we sponge Richester in 1919, two grains of me- out the ropy fluid which in a few hours thylene blue dissolved in one ounce of covers the viscera and gravitates into sterile water about an half hour before the pelvis. Although this fluid is not operation. This should be given through very infectious, we have always left a a tube to prevent discoloration of the cigarette drain to the bottom of the pel- lips and tongue. The solution goes into vis through a supra-public stab. Such the stomach and escapes through the a drain is probably in most cases un- perforation, staining the ulcer and the necessary, but it can do no harm and we adjoining tissues a deep blue. This en- believe that if peritonitis should de- abies the operator to find the perfora- velop, it might be life saving. After tion at a glance upon opening the peri- operation, the patient is put in Fowler's toneum. We have used this in our last position, with a sodium bicarbonate rec- four cases and find it very helpful. The tal drip, on two hours and off two hours, need for such an aid was forcibly A teaspoonful of cracked ice or water brought to our attention in 1918 when is given every fifteen minutes by mouth we watched the chief surgeon at Camp if desired. After the second day, a stick Jackson search for an hour, making two of lemon candy is given every three incisions, for a pin point perforation in hours to be held in the mouth until dis- the stomach. solved. We find this well tolerated by Cauterization of a perforated ulcer the patient. It is palatable, and re- takes only a minute and, unless the Sieves hunger, furmshmg carbohydrate condition of the patient is extreme, and preventing acidosis. Milk, broth, should be done. After the sutures are g^uel, and raw eggs, when liked by the placed, thev mav be pulled aside and Patient, are given m small quantities the cautery applied before the infolding on the fourth or fifth day. Food should is done. Before cauterization, we have be given often, but not much at a time, not reflected the peritoneum from about to enable the stomach to empty between the perforation, as does Balfour, but feedings, and prevent distention. None push the rounded point of a red hot of our cases have had post-operative soldering iron through the opening, be- vomiting or bleeding, ing careful not to injure the gut wall After operation, relief from the in- opposite the perforation with the cau- sufferable pain is immediate and last- ^gj,y_ ing. The patient gratefully speaks of The i-folding of non-indurated ulcers ^ow much better he feels than before is usually easy, but the closure of an operation. Convalescence in most of indurated ulcer may be very difficult, these cases is almost unbelievably May, 1922. ORIGINAL COMMUNICATIONS 241 smooth. Although the patient is dis- missed at the end of the third week with the usual careful instructions about diet, he feels so well that it is a safe bet that in a short while he is eat- ing everything he wishes. THE SPLEEN IN SURGERY* By Carrington Williams, M.D., Richmond, Va^ In early embryonic life, the spleen is developed from mesodermal tissue lo- cated nearby that tissue which forms the frame-work of the liver as it grows from the foregut. This close relation- ship to the liver is quite significant, for these two organs function together in later life. The spleen is made up of lymphoid tissue suspended on a loose retriculum, and has large blood channels which are in intimate connection with this lym- phoid tissue. It has no lymph channels except a few in the capsule. This cap- sule is made up of dense connective tissue, and contains smooth muscle fibers ennervated by the sympathetic and vagus, and capable of slow rhyth- mic contractions. The physical connections of the spleen are largely through the blood channels, which are of such significance as to deserve review. The blood from the coeliac axis and the two mesenteric arteries is returned in veins which unite to form the portal vein, and this emp- ties by division into capillaries in the liver. The artery to the spleen is the largest branch of the coeliac axis, while the bulk of tissue supplied by it is smal- ler than that supplied by the hepatic or the gastric. This blood supply there- fore may be considered to be excessive in the sense that the blood supplies of the kidneys and of the thyroid are ex- cessive. The blood from the spleen, however, must pass through the liver before it reaches the general circula- tion. ♦Read before the Tri-State Medical Associa- tion of the c\iroliii;is and S'irginia at Norfolli, Va., February 22-23, 1922. The nerve supply of the spleen comes from the sympathetic system and the vagus. The relation of the spleen and liver in action has been compared to the glomeruli and tubules of the kidneys, for the spleen extracts from the blood certain products which it passes on to the liver for disposal. This is true not only of waste products, but also of cer- tain substances which the liver must return to the body to maintain normal life. With regard to the latter func- tion, the spleen may be considered as a "scrapping plant," where the wornout blood cells are delivered to have re- moved whatever may be of further ser- vice to the body. Gaton in animal experiments found that the amount of pigment in the bile was relatively diminshed after splen- ectomy both with and without the ad- ministration of a hemolytic agent. It is interesting to note that the ab- sence of the spleen increases the en- durance of the animal ; this has been demonstrated, and is said to have been known by the Romans who removed the spleens of their runners to increase their wind. In prenatal life, the spleen actively produces red blood cells, but this func- tion is lost after birth, and its blood producing power is limited to lympho- cytes. It still performs a valuable part, however, in red-blood production by re- moving from the circulation worn out erythrocytes and passing on to the liver the iron removed from them to be in turn used by the blood-forming ele- ments in new cells. After removal of the spleen, there is a period of anaemia followed by a return to normal ; during this period of recovery, the other lym- phatic glands assume the work of the spleen. The spleen assists in producing im- munity. This is indicated by experi- ments in which Morris and Bullock have demonstrated that splenectomized rats were more susceptible to ordinary infections, and to sublethal injections of live bacteria, than were others on whom abdominal castration had been done for controls. It is well known that 242 SOUTHERN MEDICINE AND SURGERY May, 1922. the spleen can filter from the blood par- tion has been quite irregular until eight asites of disease, but it cannot destroy months ago, since which it has come these organisms. Probably the most monthly. striking example of this is the accumu- Present Illness— Eight years ago her lation of Plasmodia of malaria, the ague abdomen became quite large, apparent- cake of the tropics. The same is true ly from fluid. Previous to this, she had of the spirochaeta pallida. The enlarge- complained of soreness in the upper ab- ment of the spleen in typhoid fever and domen. After the swelling subsided, chronic infections, is due to the accum- large veins were noted in the abdominal ulation of bacteria and the reaction to wall, and the spleen was found to be the infection. This reaction of the enlarged. She soon afterwards had a spleen is usually of a chronic nature, ^arge hemorrhage from the stomach, and consists largely of a thickening of and for several days passed old blood in the reticulum and the blood vessels. her stools. These hemorrhages have Lesions typical of the disease, how- occurred since at intervals of three or ever, may be produced as is best illus- four months. She has always been pale, trated in tuberculosis. and skin has had a lemon tint. She has The mechanical condition of the grown normally in stature. The spleen spleen such as rupture, traumatic in- has slowly increased in size. During jury, and displacements, as well as the the past two years, she has been treated rare cysts and new growths, will not by an osteopath and has not had a be considered except to say that they hemorrhage for the past eight months, demand and have consistently received physical Examination— Patient is a surgical relief. fairly well developed and nourished Banti described an anaemia with young woman appearing chronically ill. splenomegaly and cirrhosis of the Pupils equal and react to light; con- liver, which he considered due to an junctiva good color. Tonsils do not ap- infection of unknown origin. This defi- pear diseased. Teeth in good condition nition of the disease is still adhered to, except one decayed molar, although since his time, the cause of Chest— Expansion good. Heart and the infection has been discovered in j^ngs negative. Abdomen is moderate- some cases, and these removed from ]y distended, and a number of large this classification. veins appear on the left side. Sharp, The infectious origin of the cases hard edge of the liver is palpated one- remaining as Banti's disease or splenic half inch below the costal margin. The anaemia, has not been demonstrated, left upper abdomen contains an enlarg- yet the similar clinical picture of those ed spleen, which extends to the midline of known infectious origin cannot be in the epigastrium, and downward to a other than impressive. The pathology line just below the umbilicus. No fluid in the spleen is that of a chronic in- demonstrated in abdomen. Extremities fection and the liver is cirrhotic. This normal. Knee jerks present, cirrhosis accounts for the varicosities Laboratory Examinations— Urinalysis in the portal system and the hemor- negative. Blood count: Leucocytes rhages from the stomach. 4,000; polymorphonuclear, 69^;; lym- The course of splenic anaemia is il- phocytes, 23';; ; large lymphocytes, 6% ; lustrated by the following case: eosinophiles, 2^/^; red cells, 4,520,000; Miss E. G., age 17. First seen June hemoglobin, 40%. A few microcytes 8, 1921, complaining of enlarged spleen, and poikilocytes were seen. Blood was- anaemia, and hemorrhages. Family his- sermann was negative. Urine was neg- tory is unimportant. Past history : She ative for urobilin. Hemolysis test: has never had any illness of note ex- Hemolysis begins in concentration of cept the present trouble. Appetite and 0.45';, and is complete in 0.25%. digestion have always been good. There Diagnosis — Splenic anaemia of Banti. are no urinary symptoms. Menstrua- She was advised to have the spleen May, 1922. ORIGINAL COMMUNICATIONS 243 treated with radium and later removed. Dr. W. J. Mayo saw her in consultation on October 22, 1921, when he was in Richmond, and agreed to the diagnosis and treatment outlined. She had an- other severe hemorrhage in October, and returned two weeks ago for treat- ment. Radium was applied over the spleen by Dr. S. W. Budd. This case has the cardinal symptoms of splenic anaemia. The anaemia is of the secondary type, and is due probably to a failure on the part of the spleen to deliver the blood pigment so that the cells produced are of poor quality. The red cells, however, are more resistant than normal, as evidenced by the dimin- ished fragility to salt solution. If we proceed on the theory that the spleen is harboring an infection picked up from an unknown source, we must conclude that removal of the spleen will cure the patient. This is borne out by the results in the splenomegalies of known infections. It is also borne out by the results of splenectomy for splenic anaemia, but the success of the proce- dure is dependent on the amount of damage already done to the liver and the portal circulation. Giffin has re- cently published the results on 71 cases of splenectomy for splenic anaemia done at the Mayo clinic. There was a hos- pital mortality of 12.6';, and subse- quent death of 31'; . Of the remaining 40 cases, 28 were heard from and 27 were in good or fairly good condition. On account of the adhesions usually present in this condition, and in the septic spleens, the operation is made more difficult and hazardous than those cases where the spleen is free. The size of the spleen formerly added to the risk, but now this can readily be reduced by application of radium before the opera- tion is done. Tuberculosis when localized chiefly in the spleen, syphilitic splenomegaly which does not respond to treatment, and the spleen of chronic malaria, have all been successfully treated by splenec- tomy. These conditions present pic- tures practically identical with the splenic anaemia of Banti. Hodgkins disease involves a large part of the lymph glandular system. Several efl;orts based on much evidence have been made to show that this dis- ease is an infection. There are other atypical lymphatic enlargements that appear to be infections; they may be illustrated by the following case: B. D., age 11 years, as seen on Oc- tober 11, 1921, complaining of swelling of the neck and abdomen. Family his-, tory negative. Past History;— He has never been sick before; he has always been strong and worked on the farm. Present Illness— Three months ago his left foot and ankle were crushed under a heavy barrel and became in- fected. Several incisions were made, and have resulted in sinuses which drained pus. There has been no marked enlargement in the groin. During this time, he has had fever, chilly sensations and sweats, and has lost weight. Ten days ago, a swelling appeared in neck; this has increased in size and has ex- tended over his upper chest. His ab- domen has been quite distended. Breath- ing has been difficult. Physical Examination — Patient is a boy of eleven years, with large swelling in neck, appearing chronically and se- verely ill. Conjunctiva pale. Teeth dirty. Tonsils small and do not appear diseased. The left side of neck extending from parotid region across the midline in front and downward to root of neck, is filled by a brawny edematous mass. This mass is not red, and there are no discrete nodules. Chest showed a small amount of fluid on each side, otherwise heart and lungs were negative. Abdo- men is not distended. Liver, spleen and kidneys were not palpated. There was no mass or tenderness, but a small amount of free fluid was present. Extremities — Left leg is smaller than the right. On the inner side of the left ankle and the outer side of the foot are small sinuses practically healed. No edema, swelling or tenderness about these sinuses. The lymph glands of groins, axillae and epitrochlears are moderately enlarged. 244 SOUTHERN MEDICINE AND SURGERY May, 1922. Laboratory Examinations — Urinaly- tomy are correspondingly less encourag- sis cloudy; 1012; acid; albumin heavy ing. Reports indicate, however, that trace ; sugar negative ; microscopic, a life expectancy is increased a few years, considerable amount of pus, many hya- while the immediate mortality is not line granular and waxy casts. high. Following the operation, there is Blood count— Red cells, 3,600,000; a remission of a variable length of hemoglobin, 54%; leucocytes, 17,400; time. polymorphonuclears, 64% ; lymphocytes, I» the leukaemias, the spleen is only 18% ; large mononuclears, 4.57c ; eosino- a part of the general pathology. Lym- philes, 13%,; mast cells, 0.5^,. Blood phatic leukaemia in the acute form pre- Wassermann negative. X-ray of chest sents a picture of a violent and rapidly showed very heavy shadows about the fatal infection. In myelogenous leukae- roots of the lungs with wide mediasti- mia, the spleen frequently grows to nal shadow, due probably to lymph enormous size, but this can be reduced glandular enlargement. by radium, and splenectomy safely A lymph gland excised from the right done. As in pernicious anaemia, the re- groin was examined and reported atypi- suits are not encouraging, cal malignant lymphoma. The spleen of chronic sepsis offers The neck was exposed to 50 mg. ra- kittle opportunity to surgery, because dium in four separate areas with a to- while it may be seriously involved, the tal of 400 mg. hours. infection is in the blood stream and can- While in the hospital, his tempera- not be removed as can the spirochaeta ture ran from 98 degrees F. in the and malaria Plasmodia by specific drugs, morning to 100 degrees F in the after- Conclusions— The spleen, while not noon. • primarily involved in infections, can be- He was advised to return for fur- ^ome a focus by removing from the cir- ther radium treatment, but his father culation organisms which it cannot de- stated in a letter two months later that ^^^o^- ^"^^ ^ ^^^"^ ^" ^^^ «P^^^" ^^"^^^ he was entirely well. He said that the ^ destructive process in the liver. While swelling in his neck had broken down infection cannot be demonstrated in and drained, and rapidly subsided, while ^anti's disease, it runs such a parallel the boy gained strength and weight, course to known infections as to deserve Except for the pathological examina- consideration as such. When the pa- tion, we would be inclined to doubt the thology in the spleen predominates, gravity of the condition, but the speci- ^o^d results may be expected to follow men was examined by several compe- splenectomy as is the case in the known tent pathologists who agreed that it was infections, Banti's disease before ex- a malignant condition, although they ^^^me cirrhosis of the liver is present, could not agree on a name for it. ^"d hemolytic jaundice. In these conditions, the spleen pa- Where the spleen is an important thology is so small a part of the whole P^'^^ ^^ ^^^^ general pathology, moder- that little could be expected from its ^^^ improvement only follows splenec- removal. Marked improvement results, ^0"^^' ^^ ^^ ^een in pernicious anaemia, however, from radium treatment ; un- myelogenous leukaemia, and late Banti's fortunately the improvement is usually disease, temporary. Where the spleen is overshadowed by In hemolytic jaundice, excellent re- ^^^^^ pathology, no results can be ex- sults have followed splenectomy. Gif- P^^ted from splenectomy, as is true of fin reported 32 cases with one hospital Hodgkin's disease and similar condi- death, and 25 patients in good or fairly ^^c>ns, and lymphatic leukaemia, good condition. References In pernicious anaemia, the spleen l. Moynihan, Sir B.--Brit. Jour Surg., does not predominate in the pathologi- 8:307, Jan., 1921. cal process, and the results of splenec- 2. Mayo, W. J.— Arch, of Surg., 2:185, May, 1922. ORIGINAL COMMUNICATIONS 245 March, 1921. average medical student leaves college 3. Morris, D. H., and Bullock, F. D.— Ann. with but a slight idea of the insidious Surg., IXX:513, 1919. action of morphine and cocaine or the 4. Giffin, H. Z.— Med. Clin, of N. Amer., easy avenue which leads to the contrac- 1919, 111:765; Minn. Med., 4:132. March, 1921. tion of the habit. If the students of our 5. Giffin, H. Z., and Szlapka, T. L.: Jour, medical colleges were well grounded in Amer. Med. Asso., 1921, IVVVI:290. this important branch of medicine it 6. Hall, M. W.— Amer. Jour. Med. Sc, 1920, would not only, perhaps, be their own CIX:72. salvation, but would, in a measure, stop 7. Gato, K.— Jour. Expt. Med., 26:795. Dec, the indiscriminate prescribing of nar- 1917. cotic drugs to their patients. Among the questions asked the physician enter- ing our institution for treatment is, THF TNrRFA«lTNr FRFOTTFNrV OF ^°''' ^® Contracted the morphine or co- THE INCREASING JKEQUENLY Ol^ ^^j^^^ ^^^-^^ ^^^ ^^ ^j^^^^ invariably THE USE OF NARCOTIC DRUGS answers that he commenced its use for BY MEMBERS OF THE MEDICAL acute pain or for the relief of fatigue PROFESSION AND THE PROB- caused by overwork, not realizing any ABLE REASONS FOR IT more than the average layman the in- sidious action of the drug. I regard it By W. C. Ashworth, M. D., Superintendent, ^^ ^ ^^^^^ ^^.^^^ ^^ ^^^ profession that Glenwood Park Sanitarium, Greensboro, N. C. ^^^^ ^ condition of affairs exist, but on The average physician is not aware the other hand, I hold that the unfor- of the appalling extent to which the tunate habitue is less blamable than his members of our profession are addicted teachers, whose duty it was to have to the use of narcotic drugs. My line of given him more information on a sub- work gives me ample opportunity to ject that so vitally concerned his future note the increasing evil to a greater de- success in the most trying of all pro- gree than is imagined or even thought fessions. of by the general practitioner or lay- Now, as to the remedy, again I would man. We find, on looking over our case suggest that a special course of lectures register, that 75 per cent of all our drug be given each class of medical students patients are physicians. This per cent on the narcotic drugs and their habit- is perhaps a little larger than is found forming tendencies, in order that the in the average institution, which may student may leave college and take up be accounted for, in part, by our direct his work with a clear and concise knowl- method of advertising to the profession ; edge of the action of these drugs and however, we do not believe that it is know that if they are habitually used much larger than is found in most in- they are a constant menace to the life stitutions. and mentality of the user, and that sure I wish to note briefly the causes which and certain dire results must inevitably are responsible for this evil which has follow in their wake, befallen so many of our medical breth- The laity have very little patience ren. It is an evil which is enslaving a with the physician who is addicted to large and increasing percentage of the the use of drugs. They say at once that best men in our profession. he, above all others, is inexcusable, be- The first and leading cause we ascribe cause he knew the action of the drug to the meager teaching in our medical before its use. I am sorry also to note colleges of the baneful effects of the that the members of the medical pro- habitual use of narcotic drugs. The fession have about as little patience with the habituated physician as the ^Prepared for the Tri-State Medical Asso- average layman has. Now the remedy elation of the Carolinas and Virginia, Norfolk, lies in the proper teaching of this sub- Va., February 22-23, 1922. ject in our medical colleges, and, sec- 246 SOUTHERN MEDICINE AND SURGERY May, 1922. ondly, with the individual himself. The drugs, which are even more dangerous physician must not entertain the idea than the most deadly explosive. The that he is immune to the temptations physician leaves his alma mater with of other people, or that his will-power the fixed belief that he can handle and, is of a superior nature to that of his perhaps, take a medicinal d@se of any layman brother, per contra we generally drug with impunity, and that he is, and find just the reverse of this condition of can always be, master of the situation, affairs. On account of his irregular This belief, perhaps, continues wntil he hours, and the constant grind on his has taken a few doses of morphine dur- nervous system, incident to his labor- ing some acute illness for the relief of ious profession, he is really more sus- pain, for which time and rest would ceptible to the action of narcotic drugs, have been sufficient, but unfortunately and the relief from worry and overwork he could spare neither, and when the ill- is more quickly sought, before he even ness has subsided he suddenly wakes up realizes the danger and subtleness that to the fact that it is impossible for him lurks in the use of these drugs. to live without the powerful anodyne In defense of the unfortunate drug and realizes, as never before, that there user, I wish to say that very few of is no such slavery as the thralldom of a them commence the use of the drug drug. Try as he may to break the fet- wantonly. Somewhere, perhaps in the ters that bind him he finds himself ancestry of the individual, you will find utterly helpless and wholly unable to the history of excessive use of stimu- cope with the situation. There is an lants or narcotic drugs, thus transmit- old adage "that a habit soon becomes a ting to the unfortunate subject a les- second nature," but when it comes to sened resistance, or a strong predilec- the use of narcotic drugs it stands first ; tion for the use of stimulants and drugs, nature is in abeyance and all the forces I find, in support of this argument, that of the body are insufficient to throw fully 50 per cent of my drug patients it off. give a history of a depraved ancestry, I wish to emphasize again, in view of or other faulty habits of living, due in the deplorable condition of affairs, that a large part.to the excessive use of nar- the failure of our medical teachers to cotic drugs or stimulants. It is natural, teach every graduating class in medi- therefore, to find the neuropathic type cine the insidiousness of narcotic drugs, or tendency in most drug users. whethed they be taken by the doctor I wish, in this connection, to reiterate himself or given to his pa, lent, is well what I stated about physicians taking nigh criminal. When the physician narcotic drugs without any more knowl- learns this lesson as well as he should edge of their habit-forming tendencies he will cease to give so much to his pa- than the average layman, and to this is tients, and, consequeatly, we shall have added the constant danger of these fewer morphine habitues among the drugs on account of their being handled laity. As an illustration of this point, daily by the physician, which places I frequently elicit a history like this him in infinitely more danger than the from a patient who is just entering for average layman. When we realize fully treatment : When questioned as to how the force of this truth we become more he contracted the habit, he states he sympathetic and have more patience was sick and the doctor visited him with the unfortunate physician who be- once a day, perhaps, and administered a comes addicted to the use of narcotic hypodermic for a period of days, possi- drugs. bly weeks, and when the illness sub- Most people who handle explosives sided the physician in attendance stated have received instructions as to their it would not be necessary to give any danger, and certain precautions are more hypodermics and by all means given for their use, but not so with the not to take any himself. What hap- physicians who daily handle narcotic pens? The patient writhes in agony May, 1922. ORIGINAL COMMUNICATIONS 247 when his accustomed narcotic is with- impenetrable mystery. The formulas drawn, forthwith sends for his regular of medicine — even as those of magic — medical adviser and is informed by him must surely fail if communuicated ; po- that the pain is largely imaginary and tency was inevitably destroyed by pub- that there is really no necessity for his lication, continuing the anodyne hypodermic. Under these circumstances, and, in The poor patient implores and beseeches many instances, the physician enjoyed his doctor just for one more, but is a reputation for high learning and a stoutly refused. What is the result ? position of unassailable authority in his The patient leaves his bed, if he is able, community. But the science of medi- but if not, sends to the nearest dru3 cine made little progress. Indeed the store and arms himself with a hypo- history of medicine shows no progress dermic for future use. The future of at all except during those periods when this patient need not be pictured, as he medical schools and medical writing now belongs to the great rank and file flourished of morphine users. Who says the poor j, ,,^, ^.^ ^,^tj, ^ ^ ^^^^^^ fellow IS to be blamed? Who is to be ^ack to his native England the note blamed most, the patient or his ill-in- ^ooks he had compiled at the clinic of formed medical adviser? I tell you, pabricius in Padua and pass on to his gentlemen, we deal entirely too lightly i,^^ fortunate medical brethren the with this question. Something must be f^.^s he had had opportunity to observe done, and that quickly, or we shall be- ^^^ collate, as well as the original con- come a nation and a profession of drug ,j^,,i^„, ^^ had drawn from these obser- users vations; only when these same medical To my mind, the solution of the prob- brethren had taken occasion to consider lem IS to educate the physician himself, the facts and dispute the conclusions, who will, in turn, save himself as well that there was any real progress in the as his patient from the clutches of the science of medicine. Had the researches "king" of all drugs, morphine. of Harvey been guarded with the same If I have succeeded in arousing your jealous secrecy which surrounded those interest concerning this very important of Roger Bacon four centuries earlier, subject I shall feel more than repaid for who knows how much poorer medicine, the time spent in writing this hastily as well as the world at large might be prepared article. today. "The tissues of the life to be All science depends upon the classi- We weave with colors all our own, fication of facts, upon the comparison 'Till in the fields of destiny, of cases alike in the main essentials but We reap as we have sown." differing in details. The development of medical science was hindered — per- haps I may say, is hindered — by the THE PRACTICAL USE OF CURRENT difficulty of determining just what MEDIC 4L LITERATURE* cases are sufficiently similar to be com- pared. It was not until the medical M. L. Townsend, M. D., Charlotte, N. c. periodical came into existence that any There was a time when medicine was such general comparison was at all pos- ranked with astrology and magic as one sible. In the great city hospitals and of the "black arts" and its practice jeal- other medical centers a relatively few ously guarded as an hereditary right, physicians found plenty of chances for The wisdom accumulated by the father clinical observation and comparison, but was handed down to the son most care- the rural practitioner, the man far re- fully wrapped in profound secrecy. It moved from the university or the hos- was taught that the very truth of the pital, enjoyed no such opportunity, precepts and the efficacy of the reme- Though the most obscure country doc- dies depended on their being kept an tor might see conditions which never 248 SOUTHERN MEDICINE AND SURGERY May, 1922. came under the eyes of the greatest drops the busy practitioner must swim masters, he was unable to make public with all his might to escape being what he had seen to the end that it drowned. It is no longer a question of might be compared and differentiated, getting a share in the current knowl- and the science of medicine enriched by edge and thought, but of selecting the his observations. truly worthy and avoiding complete It was in the eightee"nth century that engulfment in the non-essential, a local medical society was first organ- it was to meet this need that the spe- ized. Such societies were at first con- cialty periodical first came into exist- fined to the centers of population like gnce, and it now seems difficult to realize London and Paris, but it was not long how we could have had specialists at all before those living outside the reach of before we had thair particular organ of these centers also recognized the inesti- literary expression, mable value of getting together for the j^ ^^^j^ ^e superfluous to attempt to exchange of ideas and experiences, and ^^-^^ ^^^ ^^eir value to those whose local medical societies sprung up most activities are wholly directed along the everywhere. ^ . , . , . , lines they follow, but the message which Probably professional jealousies, and ^^^^ ^^^^y ^^ ^^^ profession at large is back bitmgs, existed in these former ^jj ^^^ ^^^^^ overlooked. For the special- days, but if so these have now been for- j^^ it would be fatal not to keep in touch gotten. But the proceedings of the ^j^h the advances made by other work- medical meetings, which found their ^^.^ j^ j^j^ particular field, but the gen- way into print, have many of them been ^^^1 practitioner very frequently fails handed down to us as a valuable herit- ^q equip himself with the special knowl- age, affording an interesting and in- g^g^ ^^ich is almost as essential to him structive background for the modern ^^ ^^ ^^e man who gives his entire time medical periodical. to a single phase of the riddle of medi- In the United States, Boston was the cal science. No matter how plentiful, first community to issue a real medical or accessable, the consultants may be journal, for it was there that the Boston to whom he may turn, it is still neces- Medical and Surgical Journal was estab- sary for him to understand the diffi- lished in 1812. culty and to decide who to call and when Philadelphia soon followed suit with to call him. So rapid are the advances the American Journal of the Medical made in every direction that it makes Sciences in 1820. But for many years no difference how thorough a ground- thereafter medical magazines were few ing the medical school and hospital may and far between, and the interchange have furnished, if a man is not continu- of experimental results and clinical ex- ouslj receptive of ideas and suggestions, perience was infrequent and fragmen- if he is content to jog along in the tary. beaten paths, with never a glance after Even when periodical literature be- the bolder spirits who have the courage came more common there was still a to blaze new trails — then long before dearth of really worth-while material his shadows begin to lengthen, such a between their covers. The men who man finds he has been left behind, and could see and do were not always — in the very country he thought he knew fact — were not usually the ones who so well will have become alien, had the ability to write interesting and if current, periodical, medical litera- complete records of their observations ture is a valuable aid to the older man and researches. in "keeping up" it is equally important But little by little these difficulties for the younger man in many other were overcome and today a great stream ways, and beside, no man is so young of medical periodicals pours from the that he can be fully abreast of the press all over the civilized world. In- times. The next day after he leaves stead of thirsting in vain for a few his alma mater behind there are new May. 1922. ORIGINAL COMMUNICATIONS 249 developments that supersede those he ligent in respect to a great many sub- learned the day befor in school. Before jects — commerce, mechanics, manufac- the days of the modern medical school tures, politics, but with regard to medi- the embryo physician studied his art cine it is hopelessly ignorant and never under a system of apprenticeship, im- finds it out, * * * if the community bibing his knowledge even as he ground could only be made aware of its own his preceptors powders, and learning utter ignorance and incompentence to the psychology ---f medical practise while form opinions on medical subjects, dif- driving the "one boss shay" from house ficult enough for those who give their to house and standing back as he lives to the study of them, the practi- watched his master feel the pulse and tioner would have an easier task. But dip out powders. Thus early in his pro- it will form opinions of its own, it can- fessional career he gained an insight not help it and we cannot blame it even into human nature, the fundamental, though we know how slight and decep- deshabille human nature which it is tive are their foundations. * * * given to the doctor to know as few The unprofessional experimenter or ob- others can ever know it, and he received server has no large experience to cor- a special course of instruction which no rect his hasty generalizations. * * * medical school or huge city clinic can So it is that you will find the commun- ever furnish to its students. ity in which you live, be it town or May I read, please, from Medical country, full of brands plucked from Essays, extracts of what Dr. Oliver the burning, as they believe, by some Wendell Holmes once told the graduat- agency which with your better training ing class of Bellevue Medical College: you feel reasonably confident has had "The persons who seek aid of the phy- nothing to do with it. You cannot and sician are very honest and sincere in need not expect to disturb the public in their desire to get rid of their com- the possession of its medical supersti- plaints, and generally speaking, to live tions. as long as they can. However attrac- In combating this lay attitude, so tively the future is painted to them, graphically pictured by Dr. Holmes, the they are attached to the planet with young doctor just entering practice will which they are already acquainted, find much solace, and not a little prac- They are addicted to the daily use of tical aid, by comparing his own especial this empirical and unchemical mixture problems with those which others have which we call air, and would hold on to communicated to the pages of medical it as a tippler does to his alcoholic journals. The writers may be separated drinks. There is nothing men will not from him by hundreds of miles, but in do, there is nothing they have not done, spirit they are next door neighbors, to recover their health and save their To study the psychology of patients at lives. They have submitted to be half second hand cannot equal the old fash- drowned in water, and half choked with ioned way of viewing them through the gases, to be buried up to their chins in spectacles of an older and experienced earth, to be seared with hot irons like man, but it offers the one best substi- galley slaves, to be crimped with knives tute of which I am aware, like codfish, to have needles thrust into it is to current medical literature that their flesh and bonfires kindled on their all of us must look if we would escape skin, to swallow all sorts of abomina- being "fossilized." Even though we live tions, and to pay for all this, as if to near enough to the great hospitals in be singed and scalded were a costly the large centers to be able to take ad- privilege, as if blisters were a blessing vantage of the opportunities they aflford and leeches a luxury. What more can it is a physical impossibility for anyone be asked to prove their honesty and sin- of us to gain in a day of observation as cerity ? much valuable information on a variety "The same community is very intel- of subjects as we can get from a single 250 SOUTIIEK.N MEDICLNK AND SURGERY May, 1922. evening of well selected reading. Every alls" that blood circulates. Other revo- paper you have heard read at this meet- lutionizing contributions to medical ing, which appealed to you, you have science have been made by men who said to yourself I want to read and never took medical degrees and claimed study that. It is alone, in the quiet of no title of physician — witness Pasteur, our own study, when thoughts from the There is always the possibility of these printed page burn deepest in our minds, ultra scientific, super-specialized period- Therefore, it becomes absolutely essen- icals overlooking highly valuable scien- tial that every medical man should sup- tific material. ply himself with periodicals relating not jn order to get the greatest help the only to his particular specialty— if he specialist ought to make it a point to, has one— but likewise those which will at least, "look over" all the reliable pub- give him a broad general view of the lications relating to his line of work, progress of medical science. and if his income will warrant such an It is not enough to faithfully peruse outlay, to subscribe for and bind them one magazine and "swear by it," how- all. And here let me say parentheti- ever "good" it may be, in the last analy- cally that if a man cannot earn or col- sis every periodical must have its "pol- lect enough from his profession to sup- icy," must look at all questions from a ply himself with the things essential to definite "editorial viewpoint." No mat- giving his people a fair deal he ought ter how "open" its columns are to criti- to get out — and in these days no doctor cisms and contradictions of the material can measure up to the full duty he owes presented, every periodical worthy of those who put their trust in him if he serious consideration has an "attitude" does not supply himself with and utilize which inevitably displays itself, and current medical literature. In addition just as inevitably affects any "constant to these special publications, he should reader" who depends on that single take time to examine not less than two journal for all his information. standard journals which aim to cover For the specialist, even more than the the general field of medicine. One of general practitioner, may it be said that, these should be of national circulation, only "in a multitude of counsellors there and I say it should be the Journal of the is safety." From their very nature the American Medical Association — and the journals confining themselves to the other should be his local magazine, consideration of a single branch even as The local magazine may not be the the specialist who does the same, tend most authoritative or illuminating pub- to become narrow. Moreover, they are lication to which he has access — usually prone to depend upon the contributions it is not — but every magazine, however of a few well known men, and to look mediocre, contains within it some grains with some suspicion upon anything that of worth and the potential germs of smacks of heterodoxy. While this adds future greatness. But it can never rise greatly to the impression created by to prominence unless it first has local their tables of contents, and upholds patronage. Subscribe to your local their reputations for accuracy and de- journal, read it, boost it if you can, pendibility, it has the disadvantage of criticize, oflrer constructive criticism if excluding many worthy innovations you can, and if it is not what it ought which come in from sources whose au- to be, tell the ones who carry the respon- thority has not been previously estab- sibility about its fault even though you, lished. It is well to bear in mind that yourself, can't suggest a better way. some of the greatest contributions to Any right-minded editor welcomes the science of medicine have been made helpful criticism, and does his best to by men who were ridiculed and scorned profit by it. Try to feel the same pride for their heterodoxical ideas by the in your local journal that you ought to world of orthodox dignitaries — witness feel in your state, your town, your own Harvey as he taught these "know it family. The great periodicals were all May, 1922. ORIGINAL COMMUNICATIONS 251 little ones at first and the famous writ- most valuable article on "Colitis," and ers whose work has given them an en- because at the moment I have a case of during reputation for excellence were all colitis that is keeping me awake at once young and unknown, very likely nights, a child of one of the "best fami- poor and struggling as well. lies" that simply must get well, I read If you want to publish a rare case or that article with such absorbing interest make known an interesting experimen- I could almost repeat it verbatim when tal result, let your local journal have the the paper is laid down. It gave me first chance at it. Remember that medi- some new points, renewed my enthu- cal literature is so thoroughly indexed siasm and the child happened to get that your contribution, if it is deserv- well. I forever feel grateful for that ing, will be listed where it will be with- article. In the same journal and by in the reach of seekers after knowledge chance the next article after the one along that particular line, just as much that proved my savior is another on as if it appeared in a journal of inter- pneumonia. It is brimful of pertinent national reputation. If your paper is points and also a number of proven, but not really worthy — if it is not a genuine previously unpublished observations contribution to medical science, but is and deductions. But I have no pneu- only a compilation of neatly arranged mania case and the article scarcely and smooth sounding "nothings" com- catches my eye, and certainly does not piled only for the subtle purpose of self- "register" in my brain. But next Jan- exploitation and personal advertising, uary this same child of one of the "best then have it published at home where families" gets pneumonia and my arma- this advertising might help you. mentarium and my hope have become If you have wrilten anything unique exhausted. I'd almost give my hope of or revolutionizing it is quite possible heaven for an article it seems I saw that it may prove a great uplift for somewhere sometime that clarified ex- your local paper, and in the end you actly what I want to know. Where is will lose nothing by it. Your local con- it? How can I find it? freres will feel you are one of the Altogether too much of this vast wealth family. of current medical literature is actually While it is true that the big maga- going to waste because we do not know zines offer you much which a local one l^ow to profit by it. All too many babies does not, yet it is equally true that your die, and grownups, too, because local medical journal offers you much the perfectly honest and sincere doctor which you would not look for in the cannot find just the help he needs at bigger ones. It takes up your personal .I'u^^t the time he needs it. This is just problems and gives yeu information the vital problem which confronts us none the less, but more valuable because today. The very wealth and abundance it is of purely local application. Do your of medical writings makes its practical part to make your local journal truly u«e a difficult problem, represent you and you will be repaid a "What then can we do to be saved?" hundredfold. Is there any method whereby the medi- It is not enough to subscribe for half cal man— be he specialist or just plain a dozen magazines, it is also necessary "doc"— can harvest the information to read them ; likewise to "mark, learn which is of use to him, winnow out the and inwardly digest them." And it is chaff and store the golden grain against just here that the rub comes in. Even a future possible mental famine, if one finds sufficient leisure to examine A great many people, both in and out carefully all the literature that is of of the medical profession, have sug- especial interest to him, how can he gested ways and methods of trying to "salt down" the information where he sift out the chaff and store away for can dip into it as occasion arises. In ready use the grain of current medical June a journal comes in containing a literature as well as cataloging case his- 252 SOUTIlEIiN MKDICINK AND SUIJCEm' JMay, 1922. tories and indexing all of this in some moment, but I catalog them. If I have manner that will make it easily and occasion thereafter to refer to the topic, quickly available for comparison and I can find the paper here, and imme- help when the emergency arises in the diately get access to it and read it. If daily work and for the preparation of during a reported operation on the neck papers and discussions. the internal jugular was divided, I would But get this firmly in your mind— catalog that under Vein, jugular,' and there is no place where the old adage is also under 'Neck, glands of.' In that more true, that "what costs nothing is way I not only catalog the important worth nothing," and there is no scheme papers, but also the details. * * * whereby the thing we desire in this If I read John Hunter's life and find a matter can be accomplished without statement I want to refer to, I catalog effort and stick-to-it-iveness. it under one, two or three headings. In It was back in 1897 that W. W. ^^is catalog of papers, and also my own Keene considered it worth while to ad- cases' I make cross references, as for dress a group of his students upon the example, cancer of the rectum is so importance of preserving current mate- ^^^^^^y ^'^^^^ ^^ ^^"c^^ o^ ^^^ sigmoid rial which was likelv to prove of use to ^^^^ ^ ^^uld refer 'rectum, cancer of,' them in the future. to 'sigmoid, cancer of,' and vica versa. WT 1, 1 4- M u i ij .Lu In this way I can find all cases that are I have spoken to you, he told them, n- j ». "of books, of journals and of year books, ^ ^^ but vou cannot be expected to remem- ^ similar system to this of Keene's ber all the articles you read. How are ^as one advocated by Leonard K. you going to make them useful? Just ^irschberg of Baltimore. The plan the same way you make your cases use- ^^ich he employed was suggested to ful. Have a second card catalog for all ^'^ ^^ile still a student, by that mas- such articles and books. I have brought ^^r of system as well as of medicine, one drawer of my own card catalog William Osier. This gives me a chance along to show you how it is done. I ^o interpolate that as I read the history saw, for example, the other day in the of medicine, beginning almost with the Boston Medical and Surgical Journal, by ^i^^ory of man, every outstanding figure Higgins, a case of Kraske's operation has been like Hipocrates, Harvey, Osier for imperforat rectum. In the Medical ^^^ Keene, men of system. Men who News I soon came across a second one ^^^ ^he energy and will to go to some bv Elliott, and the case I had the other trouble to assemble, classify and com- day is the third case. Immediately that P^^^ material and records. In addition I read the first two I cataloged them ^o a card index for patients. Dr. Hirsch- under "Rectum, imperforat," and as a ^erg m his second year m medical school sub-heading, "Kraske's operation for," ^egan "a system of cross references to giving the author, the journal, the vol- a" worthy contributions in the current ume, year and page. I also cataloged American, German, French, English and them under "Kraske's operation" and as Italian medical literature. Every week a sub-heading "for imperforate rectum." ^ ^0^^^ take a couple of hours from my If then, I have such a case, I can in a Practical work and retire into the libra- moment refer to all prior cases I have ^^^s and take references on cards. If seen recorded, and thus learn the advan- the subject was bacteriology, I would tages, the disasters, the results of prior ^^^ex it under that subject, with the cases, and embody them in any paper author's name and the name of the I may wish to write, and in my daily Periodical (such as Medizmisch Wochen- work can avail myself of the experience, schirft. No. 26, Vol. XXI, 1900) as two both favorable and unfavorable, of my cross references. predecessors, and, if possible, improve Now when we consider that textbooks upon their methods. Sometimes I do of medicine, like all scientific volumes, not have time to read the articles at the are quickly out of date, it can be readily May, 1922 SOUTHERN MEDICINE AND SURGERY 253 seen how valuably my card index refer- ferential diagnosis. After a physician ences is to me in writing memoirs, con- has made a diagnosis of any given case tributing original work, or delivering a all he has to do is to index it, together lecture or a clinic to my medical stu- with the complications, either etiologi- dents. * * * Every journal and cally or anatomically. * * * The book read has its annotations on these above covers the simple indexing of the cards. Every lecture heard has its gist first valuable source of our clinical filed away under its appropriate title, knowledge— our case histories. To in- easily referred to." dex now the memories of our second Though such eminent men as those valuable source of current knowledge, just quoted found a simple card index first index and file away under the name quite sufficient for their needs, others of the disease, as you will afterwards have found it desirable to employ a want to use them. As an illustration, slightly more complicated method. In assume that you have just read some- the volume dedicated to the memory of thing new about influenza. Under the William Osier on his seventieth birth- heading, "Influenza, diagnosis of," you day, William H. Mercur describes a key file away for future use under our five word index system which has much to key words, anything you have read, and recommend it. His plan, he claims, later wish to recall, that is applicable "offers to the busy physician a simple to the "Symptoms," "Etiology," "Anat- method of instantly reviewing by means omy," "Pathology or New Laboratory of key words or strings what his past Tests," or points in "Different Diag- cases have taught him. * * * To nosis," concerning influenza. No diffi- be a successful and intelligent clinical culty will be found in filing away all practitioner, one must constantly try to your information under these five single learn from study of clinical cases, but key words, or their logical subdivisions, as it is possible to recall at will only a When later you want to use this infor- certain percentage of our former knowl- mation, you simply pull one of these edge, one should also learn to appreciate five strings. the value of being able to file away case The practical clinical advantage of records for future reference. The value this plan is that it brings together, at of combmmg our own personal experi- the same time and place, all one wishes, ence with that of others as expressed to recall about past similar cases, and m literature has been beautifully epito- assembles for you, when you wish to use mized by Sir William Osier: "To study it, in the form of building stones of the phenomena of disease without books thought, all the new ideas which might IS to sail an uncharted sea, while to help you. The success of any scientific study books without patients is not to key word system is founded largely upon go to sea at all." the well known psychological fact that This author endeavored to apply to when once our perceptions and ideas are clinical medicine the clasifications used welded together in our consciousness, in the American Digest System. He they tend to persist and are easily re- asked himself: "What does clinical called. The author, in order to make medicine do for the public??" The an- this simple plan practicable, has com- swer is : A physician first clinically bined the key words of the system em- diagnoses then treats the public. Clini- ployed by Dr. J. S. Whitney of San cal medicine, therefore, begins with Francisco in his book, "List and Classi- diagnosis and ends, or should end, with fication of Diagnosis," with those em- treatment. * * * There are only ployed in the Index Medicus, and has five roads a man can travel if he wishes had all these key words mounted and to make a diaghosis, that is, the "road" arranged alphabetically on cards. All of symptoms, the etiological road, the minor subdivisions which these few key regional or anatomical, the pathological words do not provide may easily be or laboratory, and fianally that of dif- added when necessary, as the index and 254 SOUTHERN MEDICINE AND SURGERY May, 1922. material grows by merely following the away the same as reprints. Occasion- etiological and anatomical subdivisions ally two important articles will overlap of Dr. Whitney. on a page, and this necessitates making Since the publication of Dr. Mercur's the notation that the missing page will article, his card index has been commer- be found attached to an article filed in cially manufactured, and is now being another box. sold throughout the country by agents. Dr. Farlow of the Boston Medical It is a simple matter, however, for any Library says that "the great value of a intelligent person to provide himself library to a physician is well shown in with inc'ex cards and make one for him- the case of bibliographies and indexes self. of various kinds. Let us illustrate by Still another method of canning the considering the Index Medicus in the fruit of ones periodical reading is rec- hands of the physician who has only ommended by Dr. E. MacD. Staunton of his own library at his disposal. He in- Schenectady, N. Y. I will be glad to tends to be up to date and keep in close quote to you his description of his plan, touch with the latest and best literature, but personally I cannot see that it pos- On attempting to look up some subject sesses any virtues that would be espe- in the Index Medicus he finds that prac- cially desirable to me. tically not one-third of the references Of all the various schemes so far ad- which he wishes to read are contained vanced, there is not yet one that is auto- i" books and journals to which he has matic— there is no such thing as "per- access. The publishers of Index Medi- petual motion" and we will be compelled cus have often complained at its lack of to admit that if we wish to amount to support and have hinted at its possible much in this world by assembling, discontinuance. How can it be much classifying and making accessable our service unless a medical library is at supply of information and knowledge, hand to furnish the journals referred we have got to work for it. All that one to? Its value is inestimable, but prac- needs to follow the plans outlined by tically it can serve its proper purpose Keene and Hirschberg is stick-to-it-ive- only when a library can be consulted." ness and a box of plain white library Dr. Farlow believes every community cards, making sure that the index flaps ought to have its medical library and are wide enough to contain the most urges its necessity upon the profession, extended of our medical terms— it is The plans, as outlined, for making safer to get the longest on the market, practical use of current medical litera- The Mercur system requires cards of ture have been chosen for presenting to several different colors and greater ex- you with the idea not of increasing ex- penditure of time and labor, but its fin- Pense, but only of utilizing the material ished results are very satisfactory. If we each of us already have available, a man is located in or near a city having because, as I have said, it is not a ques- a fair sized medical library his periodi- tion of more literature, but it is most cal reading will probably be more ex- vitally important to very scrutinizingly tensive and his index consequently choose the most practical plan — your larger than that man who makes notes own, or that of another— of sorting out only on those journals to which he is a the worth while and storing it in some regular subscriber. And, of course, the manner so we can get real practical good card catalog presupposes that he binds from it. or otherwise preserves all publications The Index Medicus and also the serv- received. If he does not wish to keep ice of the A. M. A. cover the field most back numbers then the box files offer a exhaustively and if you find it desirable happy solution. All articles worth while to obtain regularly either of these serv- are regularly indexed and then cut out, ices you may know all that is being pub- the pages fastened together with a lished in medicine from day to day. Just Hotchkiss Stapler and these articles filedione point in this connection. It has be- May, 1922. SOUTHERN MEDICINE AND SURGERY 255 corae almost a universal custom for an References: author to have reprints made of a pub- /-,>. tt i ^ ttt ,, ,. , ^ lished article and it is also apparently ^ji> ^t^^^XP- ^.'•i^^'^f ^i ^'.'of' a pleasure to authors to send reprints ^°«*«"' Houghton, Miffm & Co., 1883. to those who ask for them. If you see (2) Keene, W. W., Literary Methods any article indexed which appeals to ^" Medicme ;_ International Clinics, 1897, your needs or your fancy, there need be Seventh Series. felt no hesitancy in asking the author (3) Hirschberg, L. K., System and for a reprint. He will take your request the Doctor ; Medical Record, 1908, as a compliment and will gladly send it IXXIV, 1090. to you. (4) Osier (quoted by Mercur),, Books Perhaps few of us realize the value and Men; Alquanimitas and other ad- and accessibility of the Surgeon Gen- dresses, 1902. eral's Libraiy in Washington. It has (5) Mercur, W. H., Simple Key Word always been the policy of the Surgeon System for Indexing, Etc.; Osier Me- General's office to make this library, morial Volumes, Vol. II, p B, Hoeber, which is generally conceded to be the 1919. very best medical library in the world, ^g^ gtaunton, E. M., Simple Method of practical use to the medical profes- ^^^ indexing. Etc.; Medical Record, sion of the country. Five years ago ixxXII, 804, November 2, 1912. Colonel McCullock read a paper at De- ,„^ 1., ^^ ^^ ^. r^ r^ t hm^ o i. -i. T«/r- u t- r i.u Ti/r J- 1 T -u (7) McColloch, 0. C. J., The Surgeon troit, Mich., before the Medical Library ^ ^^ t, t -u r. 4. j + +1, Association, in which he expressed the General's Library. Presented at the wish, and the hope, "that the doctors nineteenth annual meeting of the Medi- of the country should more .heartily ^^1 Library Association, Detroit, Mich., avail themselves of the facilities it of- "^""e 12, 1916. fers. Today General Noble, the present (8) Farlow, The Importance of a librarian, expresses himself as follows : Medical Library to the Medical Pro±es- «.T^ o- T 1 i. 1 i-i. ciion- Yale Medical Journal, XVlli, Dear Sir: In reply to your letter s^""' i *tie i»xcun.ai of July 14, 1921, I beg to advise you 1911-12, P- 307. that the policy of this library in regard ■ to lending literature to the profession of this country is to make loans through the interlibrary loan system, applica- , ,„„ „, ^^,^ Sacro-Iliac Joint- jons for which should be made through ^'^^^„^„ Gibson-Jour. A. M. A., the nearest medical or public library. Vj -.qoi These loans are made for a period of ^^y^ • u • Vif two weeks, with the privilege of exten- One case is reported in a boy eight sion upon request at the expiration of years old who was in an automobile this time. The transportation charges that was struck by a train and he was are paid both ways by the borrower, generally severely injured. Three days Old and rare books and volumes con- diagnosis of dislocation of the taming valuable plates and engravings .,. , , „ „r^^v • ^1 i • 1 1 ,1 X- 1 Ipff ^anro-iliac was made, and a week are in the restricted collection and cur- '^it sacro luac wdh ma , rent unbound literature is also not avail- later the X-ray confirmed it and did not able for loan. Every facility, however, show any fractures. Three weeks later is offered to those who come here to at operation the projecting posterior make use of the library for research [i[^j^ ^as sawed through, the adjacent "^^J:^' . , . . , . , , sacrum was freshened, the dislocation Trusting this information may be of ^ .^.^^^ ^^^^^^^^ ^^^ service to you, I am, . h ^ . "Yours very truly, ^^^ child made a perfect recovery. "ROBT. E. NOBLE, The statement is made that these Librarian, S. G. 0." conditions are rare. 256 SOUTHERN MEDICINE AND SURGERY May, 1922. SOUTHERN MEDICINE AND SURGERY the part of finite man to pit his meagre Published Monthly by the intelligence against Infinity, Omnipo- tence and Omnisscience. Charlotte Medical Journal Company ^.^ ^^^^^^^ sometimes if the tendency M. L. TOWNSEND, M. D. ( . is not in this very direction. We won- j. c. MONTGOMERY, M. D. f Editors ^^^ sometimes if our old preceptors CHARLOTTE N. C. ^^^^ ^^^ ^^'°™ wrong when they said that "Meddlesome midwifery is an in- vention of the Devil." "Read not to contradict and confute, nor to ^ wonder sometimes if we are not believe and take for granted, nor to find talk ■,■■,-, •, , and discourse, but to weigh and consider."— guilty of bemg so hidebound and super- Francis Bacon. stitious as to believe that nature's God — — has found the one really best way of bringing babies into this world and of Meddlesome Medicine. feeding them after they get here. We wonder if it is prejudice that Nature seldom makes mistakes. Na- makes us see only our side and note ture's infinite God knows pretty well that the most successful physicians are what He is doing in the unfolding of those who help nature most and inter- life and the care of His creatures, fere with nature least. That, however, Man's finite vision " often sees things is not measuring success by the noise wrong and in the interference makes a made, the columns of newspaper pub- sorry mess of nature's plans. Granted licity, or even the dollars accumulated that nature seemingly does sometimes but is measuring success by the per- make mistakes, and we see a chicken centage of long and healthy, happy with four legs or a pig with two legs, lives of their clientele, we see a hydro-cephalic child or a baby There are tastes that are easily ac- with club feet— yet even in the face of quired and things for which an appe- these unmistakable abnormalities who tite is easily cultivated. But an unde- dares to blame nature's God for the generate appetite is absolutely trust- fault. Anyway, "Nature seldom makes worthy in indicating the things the sys- mistakes." tern needs. Ignorant parents and indif- Babies were born before "God ferent doctors allow the child, or by pre- breathed into man the breath of life cept teach the child to acquire unnat- and man became a living soul." Babies ural tastes which start an endless chain have kept on coming ever since that of ills which death only will relieve, day and probably will continue in the We are not decrying scientific medi- same way for some time yet to come. cine— we are not decrying any effort to When we read the teaching of some aid nature— we are not impugning any writers we wonder how this could have one's motives— we are simplying re- been, we wonder how any baby could minding ourselves that sometimes our have been born and live and its mother zeal runs away with discretion, live without some kindly doctor to do a Meddlesome midwifery and meddle- version and pull out the feet, or as an- some pediatrics does not mean helpful other will claim in every case use an obstetrics or helpful pediatrics, but it anesthetic and forceps. does mean consummate arrogance, and By a miraculous chance one some- bigotry on the part of the narrow- times did get born without help and minded individual who knows no better then we wonder how it lived without a than to interfere without cause in na- host of scientifically trained experts ture's properly working plans. Either each with a basketful of Dos and Donts that or it means real criminal action on about milk formulas and artificial food the part of the iiidividual who puts hit? recipes. own advertising and a higher fee above May, 1922. EDITORIAL " 257 the interest and best good of his pa- ence to the flocking of the cripples to tient. Dr. Lorenz, there are plenty of surgeons The conscientious physician should in New York just as capable of treat- always be prepared and willing to step ing these cases, and the same is true of in and relieve, in so far as he is able, nearly every city in the country. Yet any dvstocia of nature's plans, but a the multitude who thronged to this real dystocia should first be proven, transient for treatment bore unmistak- The physician should know how to feed able testimony that this was not gen- the baby when its mother can't, but he eral knowledge. One can only conjee- should first find out if the mother can. ture as to the sum of unnecessary suf- No human mind has yet found out, fering and disability here exemplified, nor knows half so well, what food ele- And this is only a small corner of the ments the system needs for health and field of medicine. growth as nature does herself. An un- Publicity has enabled the Eddyite, depraved appetite of child or adult will the Osteopath, the Chiropractor and all tell more truly what foods to eat and that tribe to flourish. Why? Largely be- what to leave alone than all the Dieti- cause their specious and often ridicu- tians and Pediatritians the world has lous arguments, not being answered ever known. are, with a certain show of reason, as- Give nature a fair chance for she sel- sumed to be unanswerable dom makes mistakes. With the exception of owners of pri- n„uv^'4 t nit J- ' ""'^^^ hospitals, laboratories, etc., who Publicity for Medicine. g^in a certain amount of help in this The mention of medical ethics to a direction by inserting cards in medical layman seldom fails to elicit impatient Journals, doctors of medicine become comment. This is due to an imperfect ^^^own by the word-of-mouth method. understanding of the fact that these ^^ ^^ ^^^^^ o"ce in a while an indiscreet principles were formulated primarily newspaper friend gives a column or two for the good of the patient. Another ^^ ^"^ ^^ "-is to our enormous confusion element entering into this is the failure ^"^ chagrin. But this does not change on the part of the profession as a whole ^^^ ^^^^ ^^l^- to revise these principles to keep pace By what means can this state of af- with changing conditions, and on the fairs be remedied? Obviously not by part of some members of it to observe an unseemly campaign of competitive either the letter or the spirit of these advertising. How then? P""^^P'^^- Let the medical profession, acting There is abundant evidence of a through units of the county societies widespread sentiment for revision of and in conjunction with all friendly the present lex scripta on this subject, agencies, acquaint the reading public This sentiment was greatly stimulated through the sheets which everybody by circumstances attending the last reads— the daily newspapers— with the visit of Dr. Adolph Dorenz to this coun- truth about medicine. Remind all of try. Certainly the press-agent methods the debt due to the profession and the adopted on this occasion were deserving service it is rendering. Stress the dis- of reprobation. On the other hand, tinction between medicine and drugs, many of those most jealous for the dig- between treatment and drugging. Point nity of the profession and most scrupu- out the fallacies and expose the dis- lous in safeguarding the interests of the honesty of the hostile sects. Direct at- pubhc feel that more adequate means tention to the fact that through none should be devised for keeping the pub- of these cults have we been saved from lie infornied of progress in medicine and smallpox, yellow fever, diphtheria, ty- possibilities of relief and cure which phoid or malaria; that no "irregular" are at its doors. gave us anesthesia or antiseptic sur- As Dr. Copeland stated with refer- gery, and more than the overwhelming 258 SOUTHERN MEDICINE AND SURGERY May, 1922. majority of them in time of stress turn ly important subjects now before the for succor to those they have spent profession of the State, their brighter days in belittling and de- President Royster came forward in faming. his characteristic, wide-awake style, Establish sympathetic relationships pointing out many of the things that with newspapers and collaborate with are a handicap to real progress, and them in the publication of news items then with a courage born of conviction dealing with medical matters, reputed submitted for each problem a solution, discoveries and cures. Publish at reg- Radical changes always precipitate dis- ular intervals accounts of definite prog- cussions among independent thinking ress in medical science. ^^n and naurally the President s re- port was extensively discussed. How- Winston-Salem Meeting of North Caro- ^^er, it is significant to note that it had Una Medical Society. ^een so carefully thought out that the discussions changed it very little before The sixty-ninth annual session of the adoption. North Carolina Medical Society was ^j^^ society is this year honored by held in Winston-Salem April 26-27-28, having Dr. J. W. Long, of Greensboro, with headquarters at the Robert E. Lee as its President foi^ the 1923 meeting. Hotel. which will be held in Asheville the third The registration at this meeting was Tuesday of April. 542, while the largest previous registra- ^^^^ ^.^^ Meeting" of South Carolina tion of which we know was 471 This, ^^^.^^^ g too IS exclusive of the Hospital Asso- g^^^^ ^^^^^.^^ ^^jj ^^ ^^ ciation, which until this year has al- ^^^ seventy-fourth annual meeting, "?/', ? .1, i' f ""^ ?% f" held at Rock Hill, April 12-13, 1922. added to the attendance of the society ^^^ attendance was larger, the inter- meetings. ^^^ keener and the results perhaps more Seventy-six papers, exclusive of the Y,e\pfu\ than any meeting in the so- program for the North Carolina Pubhc ^^^^y^ history. The registration was Health Association, were on the pro- gei and more than 30 papers were read, gram and were all read and discussed g^ -^^^^^^ ^^ ^^^ business in hand was except a very few doctors who found it ^^is meeting that not a moment's in- impossible to be present. termission was taken for lunch and per- The society was honored by the help- haps most remarkable was the fact that ful presence throughout the session of this same keen interest held over and Dr. Frank Billings, Resident Trustee, throughout the second day of this ses- American Medical Association, Chicago, sion. All of the papers on the scientific pro- Dr. C. F. Williams, of Columbia, was gram were by North Carolina's own elected President for 1923 and Charles- men, and only the Wednesday evening ton was chosen as the meeting place. session was devoted to general subjects, it was in Charleston in 1848 that the discussed by invited guests. At this South Carolina Society was organized meeting Dr. Thomas McCrae, Philadel- and next year the society will celebrate phia, discussed "Some of the Problems its Diamond (seventy-fifth) anniver- of Internal Secretions ;" Dr. Frank Bill- sary, and in the city of Charleston ings, "The Policies of the American where is located the medical school Medical Association, Past, Present and from which so many of her men grad- Future ; Dr. Le Grande Guerry, Colum- uated, the society will have a real home- bia, said the last word about "Hyper- coming celebration, thyroidism and Its Treatment in the We wish to especially note the won- Light of Our Newer Knowledge." derful improvements in the society's The House of Delegates was very journal. However good it may have especially busy this year discussing and heretofore been, it is now very much trying to solve some of the tremendous- better. May. 1922. EDITORIAL 2S9 Mental and Nervous James K. Hall, M. D., Dept. Editor tive Wassermann reaction by adminis- tering to the individual the very drug commonly used to treat syphilis — sal- varsan or neosalvarsan. In his own ex- =^ perience, and in the experience of Ra- in the Journal of the American Med- vaut as well, a number of skin condi- ical Association of April 1, 1922, Dr. tions, for instance, lupus, psoriasis, acne Albert Strickler, of Philadelphia, con- and others, were treated by the intra- tributes a timely article entitled : "Re- venous use of arsphenamine, and in view of the Clinical Significance of the more than one case, the blood serum Wassermann Reaction." This test has which had given a negative Wasser- been in use for about sixteen years, mann before the salvarsan was admin- The medical profession at first reacted istered gave a positive reaction after to its use as this profession usually re- the drug was given into a vein. These acts to a medical discovery. During the patients gave no history of syphilis and period of innovation there was blind they were likewise free of manifesta- and unquestioned faith in the test; a tions of the disease. In one or two in- little later there was a period of grave stances the intravenous use of sodium doubt about its infallibility; and at caccodylate changed the Wassermann present there is sensible appreciation of recation from negative to positive, the helpfulness of the test, but its limi- Attention is called also to the posi- tations are becoming more and more tive nature of the Wassermann reaction keenly realized. The profession is in the presence of leprosy and of yaws. roughly divided into three schools with In a number of diabetics — 337 in all — reference to the value of the test. One 16 of the number gave a positive Was- group places unquestioned reliability in sermann. Various observers have at- the reaction ; another group looks upon tained a positive reaction also in cases the test as a symptom of syphilitic in- of nephritis, in whom there was no fection ; and the third group, because of other reason than the Wassermann, for the possibility of technical errors of one suspecting syphilis. In the febrile pe- kind and another, places little depend- riod of pneumonia, in many cases of ence upon the Wassermann reaction as typhus fever, and in a few cases of a diagnostic measure. malaria, during the chill period", a posi- The specificity of the test as an un- tive Wassermann has also been noted, failing reaction in the presence of syph- Strickler quotes Fordyce and others iiitic infection is assailed by Strickler who found that the blood serum of sev- for many reasons. In the first place, eral pregnant women gave a strongly the very nature and the cause of the positive Wassermann late in the preg- reaction is not understood, nor is it nancy, and a negative reaction some rationally explicable. It has not been time after delivery, ascertained just what the substance in Strickler concludes that even in the the serum is which brings about the absence of syphilitic infection blood se- peculiar reaction— whether a syphilitic rum may give a positive Wassermann toin, a lipoid body, or a cholesterin-like reaction as the result of the adminis- substance. W^assermann originally be- tration of some drug; because of the lieved the reaction to be caused by some presence in the individual of infection substance dissolved from the syphilitic with some orga: ism ; because of serious parasite. This is now known not to be metabolic disorder, e. g., diabetes mel- true. Nothing remains of the original htus; and finally, because of existing procedure of Wassermann in making pregnancy. He calls attention to the the test except his name. fact that known syphilitic infection does btrickler calls attention to the cu- not always make certain a positive Was- rious fact that in many instances the sermann, and he is sound in his opinion blood serum of an individual has been that the diagnosis of svphilitic disease changed so as to make it give a posi- should not be allowed to stigmatize an 260 SOUTHERN MEDICINE AND SURGERY May, 1922. individual unless other evidence of diagnosis and the treatment of diseases syphilis exist than a so-called positive of the mind as McLean Hospital that Wassermann. The day of the acute errors in diagnosis are occasionally clinical observer is not gone, and he made. Hoch frankly and in some detail should make use of all his diagnostic relates a number of such instances, acumen in finding manifestations of Fourteen patients in whom the diagno- syphilitic disease to stand alongside the sis of manic-depressive insanity seemed positive Wassermann or to take the justified, turned out to he cases of de- place of the reaction in its absence. mentia praecox. Features of praecox were present from the beginning, but In no other field of medicine is diag- the early predominant picture was that nosis quite so difficult as in disorders of a manic-depressive let-down. In a of the mind. The physician is beset by few cases the early diagnosis of demen- relatives of the patient for an opinion tia praecox turned out fortunately to as to the outcome of the disorder and be incorrect, and the final diagnosis was if diagnosis be difficult, prognosis is a manic-depressive psychosis, likewise risky. No one would venture As illustrative of diagnostic difficulty to be dogmatic about a matter of the and of prognostic disappointment a case mind save a god or a fool. may be cited. A woman of 40, tired Some of the diagnostic problems are and worn by war-work, became sleep- related by Dr. Theodore A. Hoch, an less, restless, irritable, depressed, self- Assistant Physician in McLean Hos- centered, self-accusatory, and appre- pital, Waverly, Mass., in an article en- hensive. Physical and mental improve- titled "Acute Psychoses with Sym.p- ment both occurred promptly, and she toms Resembling Dementia Praecox." seemed well on the way to recovery, The paper was read last year at the when she came under the influence of Boston meeting of the American Psy- active, dominating hallucinations, to chiatric Association, and it is published which she reacted with violence, pro- in the American Journal of Psychiatry fanity, and finally she became de'ment- for January, 1922. ed. The incipient condition justified the As an aid — indeed as an absolute ne- early diagnosis of a manic-depressive cessity— for a proper understanding of depression, but the condition must have a mental disorder, the physician must been that of dementia praecox from the first secure adequate knowledge of the beginning. Several other cases of like individual patient's mental make-up — kind are related by Hoch. his personality— all the tendencies, the Illustrative of the fact, on the other eccentricities, the habits, the longings hand, that bad mental heredity and a and desires, the repressions— every bad personality make-up does not doom manifestation, indeed, of mental activ- the individual to hopelessness even ity normal to that patient. Many acute when overwhelmed with an acute mental disorders are little more than psychosis, Hoch gives the details of an- exaggerations of individual so-called other case. A young man shy timid normality. fearful, self-centered, without' confi- Ihese abnormal traits and tenden- dence in self, and unable to make de- cies commingled with the symptoms of cisions, became neurasthenic, depressed some acute mental disease often beget and entirely without self-adjustment a degree of prognostic gloom that is facilities. After a few months in the eventually dispelled. On the other hospital he improved, completed the hand, a normal individual, whose men- convalescence at home, finished his coi- tal heredity is good, may even in early lege course, and finally made good and lile or m middle age develop a simple realized his ambitions. The early prog depression, for instance, which ends in nostic gloom in his case was due to the profound dementia. fact that the abnormal traits normal to . ,V'^ comforting to know that in an him were looked upon as belonging to mstitution so well equipped for the his acute psychosis. They were a part May, 1922. EDITORIAL 261 of him, but not of his acute mental in her right foot and leg, in which she breakdown. had a complete peroneal palsy, that her Hoch's article is commendable. He is hips were overlooked for seven weeks, frank. He relates, rather Bible-like, at which time she was placed on the but unmedical-like, his own mistakes. Hibbs table for reduction of the right His case reports emphasize the difficul- hip and it was discovered that the left ties in diagnosis of diseases of the mind hip was also dislocated. She had, how- and the disappointments in the work ever, never complained of the left leg to physician, patient, and relatives, of or hip. No difficulty was encountered unrealized prognostic hopes. in the reduction. This is the fortieth case recorded. Orthopaedics Alonzo Myers, M. D., Dept. Editor Roentgen-Ray Therapy in Chronic Dis- . ^. ,. » ,.r. ^«* eases of the Bones, Joints, and Ten- ^«rth Carolina Answers Present dons Herman B. Philips, M. D„ and Ily Katharine Myers, R.X., Raleigh, N. c. Harry Finklestein, M. D. — New York , , . Medical Journal, October, 1921. . V.' ^his marvelous age of ours, espe- For the past two years the authors ^^^^^ m these post-war years, a tidal have been developing a technique for wave of mterest and endeavor m child- treatment of chronic bone and joint di.s- f ^^"^ ^«, sweeping the world. It is a eases by X-ray. This has been attempt- If^ ^^^ [''"''^ Czecho-SIovakia to Old ed before but has often failed, probablv Mexico.but even trom these two coun- because of too intensive and destructive \!'^^ ^^^^ ^" ^^^^^ unsettled problems application. The authors' plan of treat- J^''^ "^^"^^ .^^^^"^ reports of child wel- ment consisted of rounds of exposure, f.f ^ activities so astonishing they read repeated monthly. The conditions re- 'il nf k:i < I 1^- , . '^^"t anything more than a word of ap- HiD Joint WW ^'^'^f'-^^'^" «^ ^^' preciation for the many individuals and A M A nf 2riQ9i '" "" ^^""^^"'' °^^^^^' ^"^ unofficial, who, in Sfprn'c na.^ "! «^ various ways, are contributing immeas- :5tei n s case was a woman 22 years 0 d who was thrown from a speeding 'Read before the meeting of the North Car- auiomoblle and hurled across the pave- olina Public Health Association, Twelfth An- ment striking the curb feet-foremost, nual Se.eion, Winston-Salem, Mondav April bne at first complained so much of pain -'-f. 1922. 262 SOUTHERN MEDICINE AND SURGERY May, 1922. urably to the cause of child welfare. the unguarded places and pointing the The well-being of the child and tha^ way for action, of the general public is so interwoven Nineteen hundred and sixteen saw that whatever affects the one reacts also two other noteworthy events: first, upon the other, so the first step in any a home post-graduate course in medi- crusade as big as this, must necessarily cine, including pediatrics, reaching 169 be the broadcasting of general health doctors; and, second, an eight months information. For 36 years an import- study of infant and maternal hygiene ant m.eans to this end has been the in two counties of the State. Health Bulletin which has now reached During this period one of the out- a circulation of 52,000 and is sent on standing achievements of preventive request to the people of the State. In medicine in this State or in the United addition to this there is a continually States was developed and later success- increasing- demand for other literature fully established. There are thousands on health subjects and the distribution of school children in Carolina today of pamphlets and leaflets yearly approx- who owe improved health and a fairer imates a million and a half pieces. chance in life and it may be life itself A study of the early history of our to the vision, courage, and singleness health work reveals many interesting of purpose which has culminated in the items of educational and legislative ef- economic correction of certain common fort, the latter, for instance, including defects of childhood, so detrimental to as early as 1881, a law requiring the health and so insidious in their efforts registration of vital statistics at the on the normal growth of both mind a^d annual tax-listing, and others relating body. to contagious diseases, protection of In the same year, 1917, the General children from epidemics, eradication of Assembly stepped right out in ihe lime- hookworm, etc. Through all the thrill- light and passed several important ing story of public health development health acts, the one most apropos to in the State goes the record of the un- this discussion being "An act to prevent failing, leadership of the medical pro- blindness in infancy? Perhaps you are fession who have "carried on" with thinking subconsciously "Just another amazing courage and vision. law to clog the statute books," but fair About 1911 a better system of county evidence of its observance is found in health work began to evolve and grad- the fact that in 1921 alone 51,883 am- ually developed until now we have poules of silver nitrate solution were twenty-four co-operating, full-time sent on request to physicians and mid- county health units and several others wives who are really meeting this obli- working independently, all of these de- gation to a remarkable degree. Should voting their entire time to intensive they falter the modern mother is ready public health measures largely affect- with a question. ing, or directly concerned with infant During the next few years splendid and maternal welfare. progress was made with communicable One Step after another and we come disease work. For the treatment of to a red-letter year, 1916, the year venereal disease eleven clinics were North Carolina was admitted to the established in as many of the larger registration area of the United States towns, and an extensive piece of educa- for deaths and the following year for tional work carried on. Valuable as- births as our registration was found to sistance, financial and otherwise, has he 96 per cent complete, thanks again been given by the Federal Government, to the physicians and others for fur- the Amerilan Social Hygiene Associa- nishing the needful information. So now tion, the American Red Cross, and the we have at our command the powerful International Health Board. We are spy-glass of facts, like the "Look-out barely touching the fringe of this' on the Mountain" searching out county frightful scourge so devastating in its by county, and by age, race, and disease effects on maternity and infancy, but May. 1922. EDITORIAL MS one of the most hopeful things at pres- enlisted in this movement which also ent is the new centure in co-operative furnishes a ready avenue for the cor- clinics for economic treatment by pri- rection of nutritional errors, vate physicians. Late in 1918, a system of sending ad- Prophylactic vaccines of a high grade visory letters to expectant mothers was and low' cost are widely Sistribute '. begun, also the distribution of litera- reaching every section of the State and ture dealing with the care of babies, carrying to thousands of fortunate mainly the publications of the Federal children protection from typhoid, rabies. Children's Bureau. Later this type of tetanus, smallpox, whooping-cough, work was expanded, the pre-natal let- diphtheria. Better still, in 1921, im- ters in revised form reached 10,465 wo- munizing doses of toxin-antitoxin were men in the next two years and a leaflet given to 10,607 children between six on summer diarrhoea was sent to the months and six years of age by co- mother of every baby born in 1919 and operating physicians of the Slate, in 1920. addition to what was given by official The midwives were personally in- county health agencies. structed by a representative of the Then there is the famous, or infa- State in a series of conferences cover- mous — as some of our leading citizens ing 88 counties with an attendance of used to term it — sanitary privy law 1,168, and by public health nurses with which is being enforced, and which an attendance of 1,150, resulting in a means in time the practical elimination marked increase in birth reports from of one source of the dangerous, fly- certain sections, in requests for silver borne, fecal diseases, especially the nitrate, and in a diff"erence in the re- diarrhoeas and dysenteries which at- porting of pre-natal cases by midwives tack our "second summer" babies. of 48 in the year previous to the con- Childhood has no more relentless, de- ferences to 834 since then, structive foe than tuberculosis which The value of volunteer lay agencies has raged unchecked throughout the in supplementing the work of official ages, but modern science has found health agencies has long been recog- some effective weapons and is waging nized by the State Health Officer and a vigorous and continuous fight from so when in 1919 the assistance of the every known angle. The National Tu- American Red Cross with its tremen- berculosis Association, through the ,dous influence and world-wide prestige State Association and many local was secured to aid in the promotion of branches, assists in raising funds public health nursing another notable through the annual Christmas Seal advance was made. The object of this Sale, and aids the State in promoting a alliance was not primarily to develop number of highly valuable educational public health nursing, but to increase projects, one of which is the rural diag- interest in and knowledge of infant and nostic clinic by means of which thou- maternal hygiene and tuberculosis, sands of incipient cases of tuberculosis However, as a by-product, the number have been discovered and placed under of specially trained public health nurses the care of physicians and the public i" the State has increased since 1919 has been widely informed as to the ^^om 3 to 45, the work of every one facts regarding the cause, prevention, touching at some point the problems of and cure of this disease. If this great mothers and children, volunteer organization had done noth- These items from reports of public ing more than launch the Modern health nurses received from December, Health Crusade— a system of teaching 1919, to April, 1922, are significant as health to children through habit forma- showing the trend of this work : tion by the daily perfomiance of cer- Pre-natal cases reported for lit- tain chores— it would have justified its erature 5,998 existence. Tens of thousands of school Instructive infant welfare vis- children in North Carolina have been its 15,633 264 SOUTHERN MEDICINE AND SURGERY May, 1922 Young children weighed, meas- the public and, if possible, find a true ured, and mothers advised solution. regarding diet 7,034 The concrete things that seem to un- Instrumental in getting sanitary derlie our troubles are (1) the various privies installed 1,066 manifestations of what has come to be Number of classes in "home nurs- known as "state medicine," and (2) the jj^g 113 extraordinary growth and popular en- With attendance of ]_']]!"-- 8,625 dorsement of the healing cults. Two The class teaching was the standard general social movements are discerni- Red Cross'course of fifieen lessons in ble when one examines the problem; home hygiene and care of the sick with and the actions and reactions engen- emphasis of infant hygiene and tuber- dered by these movements have for the ^,^lQgjg moment erected a specter, which too And last, and perhaps most funda- many of us have mistaken for an issue mental of all, the Little Mothers' —the medical profession versus the Leagues, a course in baby care, given people. to 1,010 girls under sixteen, the instruc- These two social movements are tion given by city, county and Indus- based on the most primitive biologic trial nurses according to a uniform plan attributes. The people are engaged in and svllabus. ^^^ primordial task of seeking for the Every girl is a potential mother, and good. Since the first man felt hunger this is the time to teach— between ten and, finding food, satisfied it; since the and sixteen— and when' we become suf- ^^^^ "lan felt the sweat of labor, and, ficiently impressed with the everlasting finding an easier way to obtain bread, truth of this idea we will demnnd that grasped it, mankind has been at the a place be made in the grammar school ^ask of seeking after good, and, finding curriculum for the study of infant hy- good, seeking to make it better. And giene. Victor Hugo said "There is one ^^^ way of mankind has from the be- thing that is greater than armies and Sir)ming been the experimental way; for that is an idea when it's time has century on centry men have cut and come." May not this be the idea and ^^^^d. That which men have rudely this its time? And may not this or- shaped to fit their needs, they have ganization whose avowed purpose is to compared with the more cunning work- raise the standard of public health to a^^^^nship of their neighbors, and slowly, higher level find the key to this door ^^^ ^^^^er has supplanted the good. This of knowledge and open it wide? That '« ^^^^ ^^ ^^^ law for the first man, and day is coming, and when it does we '^ ^^ ^^^ ^^r the race. This we all know shall advance in child-saving far beyond '^"^ ^^^ forget, our dreaming, and then, indeed, will "State Medicine." North Carolina not only answer "Pres- That portion of humanity which ent," but march ud with honors to the forms our environment is making some head of the class! new experiments just now. The social organism has many an ancient hunger and thirst that it has never been able State Medicine B. McBrayer, M. D., Dept. Editor to appease with the incomplete ration it has had to feed on hitherto; it has sufi'ered many a wound and bleeciing sore which, through the ages, it has A Remedy for Professional Unrest* vainly sought to cure, and for which it „ ^^ ,, „ ^ , has suffered manv things of many phy- By H. C. Macatee, M.D., Washington, D. C. . . ttt -^ ^f • / ^ "^ sicians. We witness the ancient proc- It is worth while to examine briefly ess of cut and try ; sometimes we en- some of the factors of the problem pre- gage in it ; sometimes we are amused sented by the unsatisfactory relation- bv it; sometimes we feel it. Maternity ship between the medical profession and bills, health insurance schemes, public I May, 1922 EDITORIAL 265 health institutes, social hygiene centers, manity seeks to supply a need ; we are rural ?a-i'a:ion commissions, child wel- only one of the methods of cut and try, fare stations, societies for the preven- and we came into being not because in tion of this and that, these are the the cosmic order an inviolable estate "state medicine" cut and trys that we was created in which we may of right fgg] dwell unmolested, but because mankind This brings us to the other social has thus far tolerated us as the best movement, wh^r'^. when it strikes the experiment hitherto achievH by the great current of the people's movement, race. Society is now meditating on new causes the specter that some call an experiments; we have been useful in issue to uprear. It is the counter move- the familiar ways, but we have failed ment of the organized medical profes- to be of use, or of the greatest use, in sion. and it is based on another primi- manners and for purposes for which tive biologic attribute— fear. society deems new methods desirable. We physicians are a conservative lot. Our profession is an instrument, which No matter what our origin, we no soon- is going to be modified in whatever er graduate and become established in fashion the social organism finds expe- something of a business than we be- dient, or cast awav if some better in- come apostles of the true doctrine of strument can be devised. We are clay things just as they are; or. if not, then in the potter's hands, and shall we un- of things somewhat better— for us. We dertake to sav to our Maker, "Why become, in habit of mind, aristocrats, madest thou me so?" givers of the law to those v/ithout, We do violence to our conv^cHons be- holders of a vested interest, and, true cause we permit ourselves to be domi- to the type, afraid of any movement nated by fear in the presence of a spec- that threatens the status quo. True, ter; we organize our fears into a de- we are the custodians and interpreters lusion and call the specter an issue, and of a certain store of the accumulated many summon us to sally forth and do knowledge of mankind : but the store battle with a phantom. Some name the belongs to mankind, it is the property phantom paternalism ; some name it so- of society. We mav expect, and prop- cialism; others, more frightened, give erlv so, to be called on to speak with it the worst name they can think of: what measure of authority we possess bolshevism: but they all think they see when society demands our witness; the same thing, whose true name is when society debides to apply in the Something -that - will -affect -radversely- old cut and trv fashion of that knowl- our-private-interests. Whatever it is edffe for its own needs. that society has in mind to do will be Our dutv is to act out our part as done whether it affects our private in- members of the soci^il bodv. contribut- forests or not; the social organism is on ing counsel and advice in the formula- the move in obedience to primeval in- tion of the protocols for social experi- s(i"c(. and the equallv instinctive and m<^nts, and supporting or opposing leg- self-protective reaction of our little islation designed to put them into effect minoritv can no more stay the tide than in accordance with our judgment and did King Canute. Our convictions conscience. But when, as an organized should instruct us that, whatever read- profession, as a group animated by justments are in the making, we are class consciousness, we constitute our- indispensable to humanity. Have we selves into a political bloc and seek to not in our possession all of truth and stem the tide of a social stream, we eternal value yet attained by man in do violence both to our intellitrence and the science that we represent, and will to our convictions. We Ho violence to not society require it at our hands? our intelligence because, if we apply our There is no issue between the medical bear^^s unto wisdom, we shall realize pTOfession and the public ; we are fright- that we are ourselves only one of the ened by a specter. The issue is solely experiments of mankind by which hu- one of policy to be settled by citizens; SOUTHERN MEDICINE AND SURGERY May, 1922. the duty of physicians, as such, is to minister to the sick and respond to the needs of society, whose servants we are. The Healing Cults. What shill we say of the healing cults? They are plagues sent on us for our sins; and not on us only — they are plagues on society as well. Society is plagued with them because of igno- rance, credulity, cupidity, prejudice and such like sins, but with those we are not at present concerned. The fact is, though, that society has in many of its units found the medical profession as we exemplify it wanting ; the popularity of the cults represents the individual experiments of these units of society in their search for the good ; if they had not felt the need, the experiment would not have been undertaken. Our duty under the circumstances, it seems to me, is self-examination, with minds humibled in the presence of our failures. It does not suffice to comfort ourselves with the thought that we rep- resent the best that has been attained in medicine, nor to take refuge in the thought of what society already owes our profession. It does not become us cynically and haughtily to watch un- moved the pitiful groping of our fellow men for good which they have not found at our hands. As good physi- cians and honest men we must exam- ine ourselves and our methods ; we must determine wherein we fail the public, and we must, as servants of society, find a way to help our fellow men, ig- norant, wilful and superstitious as they often are, in ways that they will follow, and speak to them in language they can understand. Two Divisive Faults. I said that the cults were plagues on us for our sins, but I did not enumer- ate the sins. There are two, it seems to me, that stand out as divisive faults, separating us from our fellow men and our full duty to them ; they are pride and materialism. Why do I speak of pride? Have we not a right to be proud of our calling, its history, its attainments and its con- tributions to mankind? Yes; but pride of that which lacks of perfection must be tempered with humility. Pride has taken hold on us in the name of science; we have been led up into a high moun- tain, and shown all the kingdoms of the earth, which should be oin-s if we would serve only science. Our schools taught us the ritual of scierce ; we were indoc- trinated with the scienti'^c method and informed with the scientific mind ; we were taught to scorn the empiric and to doubt the empirical. When we had satisfied our teachers as to our train- ing, we were dubbed Knights of Science and bade to go forth and conquer the kingdoms we had viewed from the high mountain. But, alas, pride deceived us ; the weapons of science alone could not avail to conquer those fair kingdoms and subdue them. Citadels there were still impregnable to our anns; beleag- uered people whose deliveries we could not compass by the devices of science. The realm still had strongholds impene- trable except with the weapons of art. What wonder that we attack reluctantly under the banner of art, whose leader- ship we have been taught to flout? What wonder that we fight but ill when we wield unaccustomed weapons newly tried on the field of combat? What wonder that captives in those strong- holds cheer on those hardy knights with strange device who seize the weapons of art. and. unmindful of dangers they know not of, attack and attack and at- tack? And if, under the attack, the walls . fall, one can understand the cheers of those going down in the ruins, cheering the champions who dared in their behalf. The fields which we may invade only under the leadership of art are still many and wide. Our friends the home- opaths understand this ; they have tem- pered their pride with humility, and enter the warfare equipped by both science and art. This. I believe, is the secret of their strength and their con- tinued life. Our friends the osteopaths seem to be learning that their art needs to be in- formed by science, and they show a dis- position to set their house in order. But the lesson we need to learn is the May, 1922. EDITORIAL 267 le«!Son of humility, which is the work hke a chemical, or analyzed like a min- meet for repentance for the sin of pride, eral ; and if it is sick, poisoned by its Our science is not yet sufficient for the own selfishness or wounded by the seli- needs of the people; we should, there- ishness of others, shut up in the dun- fore, culti'P.te anew, positively and ag- geons of fear or despa'r, it will be di- gressively, the sludy and application of reeled to lift itself out into "the glorious empirical art, and we should encourage liberty of the Children of God" by its by our example "nd approval the devel- own bootstraps accordirrT ^o ■'"he mate- opment among us of those who, guided rialistic formula of a me.ical analyzer by scientific training and safeguarded and labeler. by scientific traditions and associations, Materialism has affected our profes- praclice those elements of good which sional practices and personal lives in must inhere in the methods of the cults, manners that I shall not dwell on: that Unle-s we are willing to do this, we it is not pleasant to dwell on. They are must needs be silent, and continue to mann^'-s that alienate us from the peo- grow in symbiosis with whatever heal- pie, who, after ail, have a pathetic faith ing agencies society may choose to tol- in us; it survives their experiences of erate. us, and they continue their fiith in Materialism is the second sin in my hope. How do we justify that faith and indictment. Its origin and rise are well hooe, when we examine ourselves bj'' known; it is a product of the scientific this composite picture of what they era, and there may be significance in wish in the doctor? It is a pen picture the fact that its label bears the words by Henri Frederic Amiel, ^^Titten in "Made in Germany." It came to be Journal intime. 1873: worn as the garb of scientific men; it Why do doctors so often make mis- was fashionable, and scientific men takes? Because they are not sufncient- must no longer appear, in public at any Iv individual in their diagnoses or their rate, in any of the old garments of faith, treatment. They class a sick man un- Thus it has pervaded our profession, has der some given department of their nos- taken hold on our teachers and leaders, ology, whereas every invalid is really a and has had its unlovely effect on our special case, a unique example. How is professional creeds, our professional it possible that so coarse a method of practices, and our personal lives. It is sifting should produce judicious thera- in its nature a divisive fault, separating peutics? us often from the sympathy and under- The principal grievance which I have standing of that host of the afflicted, against the doctors is that thev neglect sick with those diseases whose etiology the real problem, which is to seize the lies in hopes deferred, in fears and unity of the individual who claims their doubtings, in shattered faiths, and in care. Their methods of investieation bleeding hearts. What has materialism -re far too elementarv: a doc^^or who to offer to these, either in diagnosis or does not read vou to the bottom is igno- in advice? Thrown back from us dis- rant of ess'^ntials. To me the ideal doc- appomted, they turn to those miserable tor would be a man endowed with prn- improvisations which we know as Chris- found knowle^ee of life and of the soul, tian science, new thought, unity and intuiMvely divinine anv suffering or Tj^i^"^^ disorder of whatever kind, and restor- Belatedly and reluctantly we seek to ing peace by his mere presence. Such expand the scope of our materialistic a doctor is possible, but the greater vision, and we recognize that human number of them lack the higher and in- lives do consist of more than bodies and ner life, thev know nothing of the tran- organs ; that there is a spirit to be reck- scendent laboratories of nature ; thev oned with, and we begin to formulate seem to me s'lDerficial. strangers to di- rna rviahstic laws for the behavior of vine things, destitute of intuition and tnat spirit^; It is a thing to be caught sympathy. The model doctor should be ana labeled in dreams, to oe sublimated at once a genius, a saint, a man of God. 268 SOUTllEHN ME!>ICINK AND SUHGRRY May, 1922. The Policy of Service. enthusiasm or unwarranted pessimism What, then, is the policy I would rec- concerning any one form of treatment ommend that this society adopt in the ''verferes with true scientific progress presence of the problems we have been and is to be deplored and discouraged, considering? It is the policy of service. To find the true evaluation of each Recognizing the medical profession as method and perhaps a correlation of the creature of society, our duty is to them is of the greatest import. After seek the good of the social whole, knoAv- thirty-five years' participation in the ing that our ultimate good is wrapped work the author states that while the up with it. The seeking of excellence cancer victim today has undeniably far in methods, morals and manners is oux greater chances of recovery than ever corporate task, in order' that mankind before, yet undue enthusiasm does only may find blessing at our hands ; for the harm to his cause. In cancer therapy seeking of excellence is the great task immediate results must always be dis- of humanity itself. counted a few years later. Our preoccupation should be the cor- Surgery, while meeting with some de- rection of those defects in the social or- sree of success, has not solved the can- ganization and in our own resources c?r problem. A comparative analysis which provoke in society the maladies ^f vital statistics and career statistics now discernible. We do ill to ourselves shows that in the hands of different and to society if we yield to fear and surgeons the highest percentage of all spend our energies in vain strife to career cases of a community which can maintain institutions and practices be cured by surgical treatment is 15.25 which society is determined to modify. Percent and the lowest 4.15 per cent. We may need to stand together for jus- ^^ ^^ ^11 probability less than ten per tice in the days that are to come; we ^^"t. i may need to witness strongly for truth ; From a study of the mechanism of but we shall not have to fight for ex- the action of radiation in radiotherapy istence so long as we follow the path it is evident that radiotherapy is theo- of service ; "for whoso thinketh to save retically superior to surgery, inasmuch his life shall lose it; but whoso loseth as it may destroy or inhibit malignant his life for My sake, shall find it." tumor tissue without injury or removal 1478 Harvard Street N. W. of the adjacent normal tissues. This surgery cannot do. ♦Presidential address, read before the Medi- Much haS been donS bv X-ray alone cai Society of the District of Columbia, Dec. 14, and much by radium alone. The arlvan- 1921. Published in J. A. M. A., March 25, tage of radium over X-ray lies in the 1922. fact that the same local effect can be obtained by it without the general re- ction so frequent and so severe in X- Roentgenology Robt. H. Lafferty, M. D.. Dept, Editor "'av therapy. The quotient of the depth dosage in roentorenotherapy can only be improved bv the addition of the .«econdarv and One of the sanest of recent articles scattered radiations, which form within was published in Urological and Cutane- the tissues. The larp-er the Dorfal of ous Review for January, 1922, by Isaac entrv^ the greater the ouantitv of the Levin on "The Relative Value of Sur- secondary radiations. And to obtain the gery, Radium and X-rays in Cancer nece^^s-^rv oualitv in the dep^h a lar^e Therapy." The following abstract ap- ""^'^ must be used. paars in the Journal of Radiology for The newest anparatus and rnpthoris March: m«ke it nossible to send a certain fairlv Surgery, radium and X-ray therapy """"H defined nuan<-itv of voriiafio^c into constitute today the total of all known deenlv seatei malienant fiiTvior^r.^^ — ^ C. M. Miller, W. F. Mercer, J. A. White, OBITUARY COMMITTEE REPORTS, k. T. Blackwell, Beverley R. Tucker, At tne recent meeting of the North and probablv others. At the meeting Carolina Medical Society, the Obituary of the American Therapeutic Society Committee reported the following mem- tribute to the memorv of the late Dr. Ders ot the society as having died since Edward McGuire, of Richmond, was the report of the committee one year paid bv Dr. Tucker. Ash by, T. P... Mt. Airv. Raird. .John. Sr.. Mans Hill, Aug. 1 (5 i-joi Barefoot. J. J.. Graham Rattle K. P., Raleigh. March 23 19'-' Rolton. Mahlon. Rich Square. Aug "VlO-'i Rrnok.s, .1. E.. BUnving Rock. May 19 ■l9-M Rullock. n. \v.. Wilmington ' ' ' G Idwell. Daniel 'Greenlee, Concord M-,v 1" G'ark, Georg I... Clarkton. Jan. 24 19-'" Co -Ue. G. W.. Mooresville. Davis. R. M.. Bryson Cty. July 7 19>1 Dew, S m'l B., Bailey. Ramefl Richard. MocksviUe. Ju'y 20, 1921. F-^r,M. o«-ar. Ooldsboro. June " 29. ' 192"l Elliott. John R, Sr. Highlands. June 27. 19-'' bnrthins-^Fi-ed. Boone (last Jr. Col.), Feb. 23 Ferguson, K. M.. (-imoron ( Indi inapolis) April 24, 1921. Fri.>-b..e. T. J.. Spring Creek, Goodman. E. G.. Lanvale. April 28. 1921 Hatch. P. R„ Youngsville, Aug, 6, 1921 Commencement exercises of the Med- ical College of Virginia in Richmond will be held on Mav 27-30, inclusive. The baccalaureate sermon will be preached by the Rev. Dr. H. D. C. Mac- Lachlan, pastor of the Seventh Street Christian Church, of Richmond. On Monday afternoon of commencement week the Board of Visitors, the Fac- ulty, the students and the alumni will parade the streets of the city. The leading feature of the parade Mill be the float which will later be used also in the Virginia Historical Pageant. This float will be an exact replica in minia- ture of the old medical college building Hawkins, Alex Boyd, Raleigh, April 4, 1921. —in this country a Unique example of 270 - SOUTUEU.N MEUICLNE AND SURGERY May, 1922. Egyptian architecture. On Monday with necessary adaptations to the ispe- night the classes that have graduated cial work required. This sanatorium in the years gone by will reunite at the was built during the war by the Army banquet table, and immediately after- and was later turned over to the U. S. wards there will be a meeting of the Public Health Service. General Alumni body. On Tuesday morning the alumni will meet in a busi- At the regular meetmg of the Rich- ness session; on Tuesday afternoon a mond Academy of Medicine and Sur- reception will be tended to the visiting gery on April 8, a paper of unusual m- ladies, and clinics will be held also dur- terest was presented by Dr. W. Lowndes ing the afternoon. , The baccalaureate Peple entitled "Silent Stones." The address will be delivered on Tuesday opinion was expressed that m many night, in the Strand Theatre, and the cases the stone which gives rise to no graduating exercises will follow imme- symptoms, and is apparently doing no diately with the award of diplomas. A harm, should be let alone, whether in ball will be held afterwards. the biliary tubes or in the urinary Every present indication is that the tract, coming commencement will be the larg- Dr. W. H. Higgins reviewed in some est and the most enthusiastic the Medi- detail the condition of a woman of 36 cal College has ever known. Alumni who had suffered for many years from from all over the countrv will be in migraine. Nothing in the physical do- attendance, and the class reunions will main could be found of which the head- be largely attended. ^.che might have been regarded as a reflection. The use of the duodenal tube __,,,., . -r.. 1 J in exciting the flow of bile proved use- ..^'•.r^^ y- ^"^,^^^^"' ^' ^''\r ,' f^l "^ alleviating the discomfort. The Va., attended, on the evening of May 1, ^^^ discussed by Dr. W. L. Peple at the University Cub, in Washington ^^^^ ^^ ^ ^ ^^^^.^^ City, a reunion of the former medical officers of Camp Greene. He renorts At the meeting of the Academy on the presence there also of Dr. S. H. April 22, Dr. A. L. Gray talked in most Lyle. Franklin, N. C; Dr. G. A. Renn, interesting fashion about "The Possi- Norfolk, Va.. and Col. W. L. Sheep, a bilities of the X-ray Examination of the native of Elizabeth City, N. C, who Head." The helpfulness of X-ray ex- is still in the regular army. The Sur- amination as a part of a general exam- geon-General is said to have r)leased but ination is dependent unoi the fact that not to have surprised the banqueters substances of different densities cast by the statement that the Base Hospital shadows diflfering in anpeara-ce. and it at Camp Greene had a perfect record, is in the nroper internretation of these sha'^ows that the SDec'.''list in this work Tuberculosis School — A tuberc'ilosis is of real service. Dr. Grav spoke with school will be conducted bv the U. S. grea^- clearne=:s, and his r.'-pisentation Public Health Service. June 1-30. at the was discussed by Dr. C. C. Coleman, Dr. government tuberculosis sanatorium at D. D. Tallev. and others. Oteen, N. C. The class will consist of Dr. PpuI W. HowIp read a p^ner on thirty medical officers and thirty nurses, "Ureteral Calculi."- Hp reviewed rather who will be drawn for the most oart brieflv but thoroughly the theories deal- from other public health service hos- ^^^ with the causation of these storpc, ; pitals. A few others who are identified the different types: the causes of the with tuberculosis work in different ^'arions situations in which thev are parts of the country, although i^ot em- found: symDtoms. anH diaornostic meth- ployed by the governmant, will be ad- '^ds of localization. Dr. Howie o-ave ex- mitted. The first school. Avhicli ^'^i<"i at Camden, Apr«, S^ " ^ ''"''' "' " community ^pital. Hpplfh r^^^~ ^T , "^he three new buildings to be erpc^Pd tion o"th?Sourh^Vayolna n' T% ^' ""^ ^'^'^ «°^P''^' *" the Infane Health and th^U S Public Health Ser ^'"'^'""°"- ""' ''"^t $103,000. TC '; p^rio^dTt "ear in'S'r- "'^'rj!'' ^■•'"-" ^'- Li-lnton, one year in Greer, aged 53, died March 12, 1922. 272 SOUTHERN MEDICINE AND SURGERY May, 1922. Dr John W. Dupree, Simpsonville, S. for the Treatment of Tuberculosis at Ch^sbLn appointed a member of the Sanatorium, N. C recently vis ed r'iw Roard of Health friends in Richmond, Va., on his return City Board ot Healtn. ^^^^ ^^^ meeting of the American Con- The Charleston County Tuberculosis gress of Physicians and Surgeons in Association has obtained the old Gov- Washing:ton City^^ ernment remount station, near Charles- ^ „ ,„ x„A^^^n^ who nrrnoies ^^^^^ tendent, placed himself, his staff, and Dr. Frank Kennedy Holman, Sumter, the institution at the disposal of th S. C, aged 46, died February 23. class, and an interesting and profitable ' ^ day was spent. Dr. William Lawrence Mauldin, Jr., ^^^ ^^^ Greenville, aged 43. died March 3. ^^^_,^ associated with Dr. Manfred Call . as a member of the medical staff of the Dr. Alonzo E. Clough Madison died gtuart Circle Hospital, in Richmond, February 26. Va., has gone to Roanoke to become medical chief of the Lewis-Gale Hos- Dr. Josepr Evans Brunson, Ninety- pjtal. Dr. Porter is a graduate of the Six, aged 72, ;died February 20. Medical College of Virginia, class of 1911. He served his internship in Rich- Dr. William Virginius Brockington, mond and in the University of Pennsyl- Kingstree, died March 9. • vania Hospital, Philadelphia, and he served throughout the World War in Dr. James Jeter Glenn, York, aged Base Hospital 45. Dr. Porter is an un- 34, died March 1, from pneumonia. tiring worker, a thorough-going diag- nostician, and his going to Roanoke Dr. Adolf Myer, of Johns Hopkins will add enormously to the medical re- Hospital, was recently in Richmond, sources of that progressive city. Va., iri consultation. MISCELLANEOUS Dr. Paul V. Anderson, of Richmond, attended the recent meeting of the Medical Society of the State of North Carolina in Winston-Salem. Plea for Early Recognition of Urologic Conditions. P. A. Jacobs, Cleveland (Journal A. Dr. and Mrs. J. Morrison Hutcheson, of Richmond, Va., are being congratu- ,, . ^, ^ ,ooo\ ^- 4- ^u^i- „.i.,o lated-twins-a boy and a girl were ^- A- May 6, 1922) states that valua- born to them two weeks ago. ^le information is obtained m urologic cases from a careful exammation of the Dr. W. C. Finnoff. of Denver, Col., a Patient, combined with a careful exam- well known ophthalmologist, recently i^^tion of the urine. He cautions that visited Dr. Emory Hill in Richmond, one should not treat every case of py- Va., and delivered a lecture to Dr. Hill's uria or hematuria, either with or with- class in the Medical College of Virginia out urinary disturbances, with drugs on tuberculosis of the eye. and bladder irrigations indefinitely. Pus in the urine, blood in the urine and dis- Dr. P. P. McCain, a member of the turbances in the function of micturition medical staff of the St^te Sanatorium are definite signs of a pathologic condi- May, 1922. MISCELLANEOUS 273 tion of the urinary tract that demand ment, and that a number do not show serious consideration. Cystitis, so-call- evidence of malignancy either by palpa- ed, is a symptom of some pathologic tion or by symptoms, while only 8 per condition of the urinary tract and not a cent of untreated patients survive to distinct entity. By applying modern their third year, prevents the abandon- urologic diagnostic methods, a correct ment of this form of therapy. The re- diagnosis can be made with a reason- suits emphasize, however, that the able degree of certainty. Then, and treatment is applicable only to a select- then only, can this class of cases be ed few ; to apply it to" all patients with treated along proper lines. carcinoma of the prostate is to encour- age false hopes and cause results dis- „ .. . ^ ^ ... r, . . heartening to both patient and physi- Radium in Cancer of the Prostate. cisiu. Hermon C. Bumpus, Jr., Rochester, Minn. (Journal A. M. A., May 6, 1922), Anesthesia in Treatment of Botulism. reports that at the Mayo Clinic 729 cases of cancer of the prostate have ^" ^^^ ^o^^^e of mvestigations de- been treated with radium during the ^'^ned to establish the path of absorp- last seven years, and 363 have not been ^^^n of botulinus toxin m guinea-pigs, a treated. In 297 cases, plates were made "u^ber of animals were kept under of the chest, spine or pelvis, and in ^^^^r for the purpose of surgical manip- eighty-four (28.28 per cent.) metastasis "lotion. It was observed by Jaquez was demonstrated, the greater number Bronfenbrenner and Harry Weiss, Bos- most commonly in the lumbar sacral ^on (Journal A. M. A., June 18, 1921) region. Sixty-one of 218 roentgeno- ^^^^ ^^^^^ ^'^s greatly delayed in such grams of the chest showed metastasis, animals following the introduction of From the facts that 73 per cent of 113 ^^rge amounts of toxin. The question patients with metastasis died during f ^"ce arose whether advantage could the ensuing year, and that the average ^e taken of this delay in the rate of the length of life after examination was Progress of botulinus intoxication under seven months, it does not seem justifia- ^^her anesthesia to permit toxin-anti- ble to treat a patient with radium sim- ^o^^" combination to take place. Various ply for the local effect obtained on the experiments were made and the cor- original growth. If patients with glan- rectness of the theory was established, dular metastasis alone are added to the I" addition to this direct effect of anes- 28 per cent of patients in whom metas- ^hesia on the progress of intoxication, tasis is detected by the roentgen ray, it attention is called to two other benefi- seems a conservative estimate that one- ^^^^ factors. The patient throughout third of all patients with carcinoma of ^^^ progress of botulism remains con- the prostate will be unfit subjects for ^cious of his condition and apprehensive radium treatment because of metasta- ^^ ^^^ significance. Anesthesia for a sis. Since only eight of the 217 patients ^ime relieves this mental distress. More- treated with radium are alive after ^^'^r, as the amount of toxin ingested three years, it will be seen that the re- ^^ unknown, it is advisable to give very suits are far from satisfactory. How- ^^''^^ ^o^^s of antitoxin intravenously, ever, the average extension of life for Etherization is known to counteract the one year as a result of the combined tendency to anaphylactic shock. method of administration is significant, and demonstrates that by careful selec- Surgical Treatment of Gastric and tion of cases and care in irradiating all Duodenal Ulcers. portions of the gland, better results may j. Shelton Horsley and Warren T. be expected in the future. The fact Vaughan, Richmond, Va. (Journal A. that 27 per cent of the living patients M. A., May 6, 1922), emphasize that are now in their third year after treat- stereotyped procedures have no place 274 SOUTHERN MEDICINE AND SURGERY May, 1922. in the treatment of gastric and duode- are, as a rule, at a higher level than nal ulcer.- Each case must be consid- those determined by the Myers and ered on its own merits. That there are Bailey modifications, and the latter early ulcers which can be successfully higher than those by the method of Fo- treated medically, no experienced in- lin and Wu. The range of variation, ternist or surgeon will deny. But be- hoiwever, in the figures obtained by each cause of this fact, one should not blindly method is practically the same. A se- endeavor to treat all ulcers solely by ries of twenty-five normal persons ex- medical methods. One might as well amined during cold weather in March attempt to cure an indolent ulcer of the and April, by the Benedict modifications leg by rest and elevation for twelve alone, yielded blood sugar figures rang- months or longer, when the same re- ing, with one exception, from 0.126 to suits can be more effectively accom- 0.171 per cent. The lowest of these fig- plished in twelve days by the proper ures is higher than the generally accept- surgical procedure. There has been a ed upper limit of normal by other meth- tendency among internists to treat gas- ods, namely, 0.120 per cent. The excep- tric ulcers only by medical methods, and tion referred to is 0.098 per cent. In a among surgeons always to operate. The series of nineteen normal persons exam- best interests of the patient require ined in the hot weather of July and closer co-operation between surgeon August, the figures by the Benedict and internist than has hitherto been the modification range from 0.107 to 0.136 vogue. If it has been decided that a per cent, by the Myers and Bailey modi- case should be treated surgically, the fication from 0.094 to 0.130 per cent, method best fitted to the condition and by the method of Folin and Wu found at operation should be chosen, from 0.075 to 0.115 per cent. The re- Routine gastro-enterostomy in all ulcer suits by four different methods of a se- cases will give as unsatisfactory event- ries of five experiments on the recovery ual results as routine pyloroplasty. The of glucose added to beef blood and sheep treatment of the patient with duodenal blood show that the Benedict modifica- or gastric ulcer is not completed with tion yielded in each case a higher per- the operation. Appropriate medical su- centage recovery than the other three pervision should be continued for a long methods. The three other methods period to prevent additional damage, yielded percentages of recovery quite The patient's general condition must be comparable to one another and closer to studied and treated. Infection else- the theoretical than did the Benedict where should be eliminated. The pa- modification. Bloo sugar determinations tient's resistance must be built up and were made on three succeeding days in the diet carefully controlled to prevent a case of diabetes mellitus in which the renewed insults to the convalescing or- patient was under treatment. The fig- gan. ures were obtained on each day by the three methods under investigation. On Comparison of Several Clinical Quanti- each succeeding day, each method tative Blood Sugar Methods. showed a decided decrease in blood su- Comparative blood sugar determina- gar percentage. However, the percent- tions were made by William Thalhimer age differences between the figures ob- and Helen Updegraff , Milwaukee (Jour- tained on the three successive days were nal A. M. A., May 6, 1922), by three greater by the Benedict modification diflferent methods, the Myers and Bailey than by the other two methods. In a and the Benedict modifications of the glucose tolerance test in a case of arth- method of Lewis and Benedict, and the ritis deformans, blood sugar determina- latest modification of the method of Fo- tions were made by the same three lin and Wu. The results obtained show methods. Here the percentage diflfer- that the blood sugar percentages as de- ences in the figures obtained at differ- termined by the Benedict modification ent intervals by each method were in May, 1922. MISCELLANEOUS quite close agreement. The figures by the Benedict modification were at a dis- tinctly higher level than those obtained by the Myers and Bailey modifications, and the latter at a distinctly higher level than those obtained by the method of Folin and Wu ; but the curves run very nearly parallel. DiflFerential Diagnosis of Diseases of the Mediastinum. To promote greater assurance in the differential diagnosis of the different infections of mediastinal disease, an ac- curate knowledge of the anatomy of the mediastinum and of the physiology of its structures, John Phillips, Cleveland (Journal A. M. A., May 6, 1922), says, is of primary importance. For the es- tablishment of the diagnosis, the re- sources of the clinical and roentgeno- logic laboratories should be called into service, their findings being added to those of a painstaking physical exami- nation and searching anamnesis. It is only by relating the general character- istics of the various types of diseases which may invade the mediastinum to all the clinical findings in the individ- ual case that an accurate diagnosis may be established. Most of the clinical phenomena associated with pathologic :onditions in the mediastinum result from pressure on some one or more of the important structures contained in it. It is therefore an important aid to diagnosis to be able to relate the symp- toms in an individual case to the struc- tures which are primarily involved. The importance of a careful and searching inquiry into the history of a patient in whom disease of the mediastinum is suspected cannot be overestimated. The physical examination should be com- plete, and should include a neurologic examination. A rectal examination should never be omitted. If any doubt regarding the diagnosis remains after a careful physical examination of the chest, either a fluoroscopeic examination or roentgenograms of the chest should always be made. Excluding aneurysm, tumors of the mediastinum form the most interesting and the most import- ant group of diseases of this region. These may be primary or secondary, malignant or benign. Almost every type of tumor may be found in the mediastinum. Simple mediastinitis, in which there is a low grade of inflamma- tion of the mediastinal tissues without suppuration, sometimes occurs. Sup- purative mediastinitis is always a se- rious disease. It is not commonly as- sociated with tuberculous disease of the lymphatic glands. Tuberculosis may involve any of the groups of the medi- astinal glands, but the tracheal and bronchial glands are most frequently affected. Mediastinal emphysema may occasionally result from inflammatory conditions in the mediastinum, the air gaining access into the mediastinum from a perforation of the trachea or bronchus, or making its way from the neck beneath the deep cervical fascia. Madura Foot, More Properly Called Mycetoma. One of the two cases reported by Gus- tav A. Pagenstecher, San Antonio, Tex- as (Journal A. M. A., May 6, 1922), is a very early form of mycetoma, involving a foot which shows early bone changes, with a later and more pronounced soft tissue involvement. The second case was a much further advanced form of mycetoma, the involvement being con- fined not only to the foot but also to the ankle and the distal portion of the tibia and fibula. The two cases are charac- teristic of typical Malura foot, or myce- toma. The history of the injury is clear in each instance, both patients be- ing laborers and forced to make their living by manual means, closely asso- ciated with the soil, going barefooted a great deal while at work. Both cases showed the pathognomonic granules in- soluble in acetic acid, containing central clumps of closely matted mycelial threads. Jutting from the periphery of the granules were branched segment- ed mycelial threads containing what could be easily i#terpreted as a nucleus. This fact clearly demonstrates that the mycelial bodies are vegetative in char- acter. SOUTHERN MEDICINE AND SURGERY May, 1922. Table of Contents for May, 1922 O.ginal Communications Torsion of the Spermatic Cord with Gan- grene of the Testicle — Report of Two Cases, by Hamilton W. McKay ,M. D._ Treatment of Chronic Empyema, by Frank S. Johns, M. D Pertinent Considerations in Hypertension, by W. W. Sylvester, M. D Editorials. Meddlesome Medicine Publicity for Medicine 229 Neoplasmata of the Clitoris,- by Frank D. Worthington, M. D 234 The Philosophy of Group or Rather Co-op- erative Practice, by J. E. Rawles, M. D. 235 Acute Perforation of Duodenal Ulcer, by George H. Bunch, M. D 238 The Spleen in Surgery, by Carrington Wil- liams, M. D. 241 The Increasing Frequency of the Use of Narcotic Drugs by Members of the Med- ical Profession and the Probable Rea- son For It, by W. C. Ashworth, M. D.__ 245 The Practical Use of Current Medical Lit- erature, by M. L .Townsend, M. D 247 Winston-Salem Meeting of N. C. Med. So- ciety Rock Hill Meeting of S. C. Medical Society Department Editors. Mental and Nervous, Jas. K. Hall, M. D... Orthopaedics, Alonzo Myers, M. D Nursing State Medicine, L. B. McBrayer, M. D X-Ray and Laboratory, Robt. H. Lafferty, M. D. News Items _. Miscellaneous 256 257 258 259 261 261 2G4 268 269 272 OjE*io»jrs of tlxe Trl-Stcite JVfecllo»l >V(Ssooi»1:lon President — Dr. S. S. Gale Roanoke, Va. Vice-Presidents — Dr. W. B. Driver Norfolk, Va. Dr. I. P. Battle Rocky Mount, N. C. Dr. R. B. Epting Greenwood, S. C. Sec'y-Treas. — Jas. K. Hall Richmond, Va. EXECUTIVE COUNCIL One-Year Term* Dr. W. L. Peple Richmond, Va. Dr. J. P. Matheson Charlotte, N. C. Dr. Chas. A. Mobley Orangeburg, S. C. Two-Year Term Dr. J. T. McKinney Roanoke, Va. Dr. C. O'H. Laughinghouse Greenville, N. C. Dr. D. L. Smith Spartanburg, S. C. Three-Year Term Dr. F. C. Rinker Norfolk, Va. Dr. J. W. Long Greensboro, N. C. Dr. George H. Bunch Columbia, S. C. The next annual meeting of the Tri-State Medical Association will be held in High Point, N. C, February, 1923. Officers of t\x& IVortla C^roliin^ IVI«=icHo^l {Sooiet>r President, Dr. J. W. Long, Greensboro. 1st Vice-President, Dr. Fred. M. Kane's, Winston- 2nd Vice-President, Dr. T. C. Johnston, Wilming- ton. 3rjJ Vice-President, Dr. B. L. Long, Hamilton. Secretary-Treasurer, Dr. L. B. McBrayer, Sanato- rium. Councilors. 1st District — Dr. H. D. Walker, Elizabeth City. 2nd District — Dr. John Rodman, Washington. 3rd District— Dr. E. S. Bullock, Wilmington. 4th District— Dr. K. C. Moore. Wilson. .5th District— Dr. A. McN. Blair, Southern Pines. 6th District— Dr. J. M. Templeton, Gary. 7th District — Dr. B. J. Witherspoon, Charlotte. 8th District— Dr. Watt Cole, Greensboro. 9th District — Dr. C. M. Van Poole, Salisbury. 10th District— Dr. Eugene B. iJlenn, Asheville. Committees Elected. Publicatior — Dr. J. Vance McGougan, Fayetteville; Dr. E. A. Lockett, Winston-Salem; Dr, M. L. Townsend, Charlotte. Obituary— Dr. Charles O'H. Laughinghouse, Green- ville; Dr. E. T. Dickinson, Wilson; Dr. W. L. Dunn, Asheville. Public Policy and Legislation — Dr. H A. Royster, Raleigh; Dr. J. M. Parrott, Klnston; Dr. K. P. B. Bonner, Raleigh. Scientific Work— Dr. E. J. Wood, Wilmington; Dr. R. N. Duffy, New Bern; Dr. C. A. Shore, Raleigh. Finance — Dr. J. T. Burrus. High Point; Dr. J. B. Wright, Raleigh; Dr. A. D. Parrott, Kinston. Delegates. South Carolina Medical Society — Dr. J. S. Bro*n, Hendersonville; Dr. T. C. Quickie, Gastonia; Dr. R. L. Payne, Monroe; Dr. W. D. James, Hamlet; Dr. J. O. McClel'and, Maxton. Virginia Medical Society— Dr. B. C. Willis, Rocky Mount: Dr. S. M. Harrell, Tarboro; Dr. Eugene Gray, Winston-Salem; Dr. J. W. Tankersly, Greensboro: Dr. B. C. Nal'e, Charlotte. American Medical Association — Dr. K. P. B. Bon- ner. Raeigh. two years; Dr. J. F. Highsmith. P'ayetteville. 1 year. The next annual meeting of the North Carohna Medical Society will be held in Asheville, April, 1923. Southern Medicine and Surgery Vol. LXXXIV ' CHARLOTTE, N. C, JUNE, 1922 No. 6 ^^.r. ^^T ,.x.T^T/^AT antitoxin? — not to mention hundreds of REFLECTIONS ON MEDICAL ^^^^^^ ^^^^^ ^^^^^ conferred boons on ETHICS ^^^ No! the most emphatic tenets of By Davis Furman. M.D., Greenville, S. C. ^^^^.^^j ^^^.^^ ^^^^ ^^^^^^ ^^^^ ^^ gladly and freely hand to humanity I am going to take you away from whatever has been discovered for the the routine of shop for a ramble m alleviation or cure of diseases and to another realm of medicine— and I feel condemn, as despicable quacks, all "who that I have a new apology for this di- j^^ke a secret of cures." gression. Having had requests for reprints of Since nation-wide publicity, reaching ^n article read some years ago, the sub- to every obscure cross-roads news pa- scriber has determined to again inflict per in the land, has been given to a jt q^ his friends. The liberal retouch- speech delivered a few days ago by j^g ^jth colors from the masters may that otherwise useful man, Royal S. have destroyed its identity, changing Copeland, reflecting on Medical Ethics, the original fabric into a veritable "Jo- it is time for' the profession to take seph's Coat." Though it lacks sym- notice. As it indicates that some, at metry, it may serve to help some to legist, besides the "I know it" have little keep' in harmony with their environ- conception of the real meaning of the ment. term. When a man like Copeland gives Lapse of time has dimmed and made voice to such statements as "the Code inroads on the old copy, therefore no of Medical Ethics is the most antiquat- bibliography will be attempted, ed, moss covered germ ladened institu- if the paper appears platitudinous or tion in the world" and that "the so- pedantic to some, the writer will not be called Code of Ethics of Doctors who surprised. If perchance, in any in- make a secret of cures of various sick- stances, the language and ideas of an- nesses and the profession through the other are used, without giving due ages who has chosen to make itself a credit, to such we humbly apologize; if secret thing and who alludes to the dark it proves helpful to any one its mission secret things of the profession (per- is accomplished. haps because some medical men were No attempt will be made to give a small enough to fight the work of the resume of the rules of Medical Ethics, justly renowned Lorenze) by his own Having, however, reached the point in language convicts himself of what it is life where the retrospect is greater than charity to ascribe to simple ignorance the prospect we shall indulge in some on the part of its author. generalizations, calling attention to Is it possible to think of Jenner as some landmarks which appear note- the Collector of Croesus like royalties, worthy or conspicuous in review. With- on his vaccine discovery? or of Pasteur out thought of presenting anything demanding cash for his method of pre- new on this old but most important venting hydrophbia? or of Behring phase of medicine, we shall attempt to withholding from dying children for collate from the great literary store- bloocl money, his discovery of diphtheria house, a few half forgotten inspiring ~' excerpts, legacies from sages and schol- *Read before the Tri-State Medical Associa- ars, in and out of the medical profes- tion of the caroiinas and Virginia, Norfolk, gjon, which have more or less bearing Va.. February 22-23. 1922. On Medical EthicS. 278 SOUTHERN MEDICINE AND SURGERY Juno, 1922 The incomparable Fuller wrote: "Well did the poets feign Aesculapius and "Circe brother and sister for at all times (in the opinion of the multitude) witches, old women and imposters have had a competition with doctors." In the fight with the inexorable, "the last enemy," whether the weapon of fate be hydrophobia, Anurism or fail- ing compensation, the attendant is of- ten rewarded by the public for his anx- ious hours of self sacrificing toil with criticism and reproach for his failure, and often as far as the public appraise- ment goes verifying the lines of Emer- son: "The valient warrior famoused for fight- After a hundred victories once failed. Is from the book of honor razed quite — And all the rest forgot for which he toiled." No honest physician will, by silence, . „ , . give quasi sanction, to such ungenerous make medical practice answer its conduct towards a colleague. It is un- ideals, this pure and noble sentiment professional and ignoble to fail to de- must always prevail. ^^^^ ^^^ reputation of an absent broth- From this fundamental concept he er when justice demands it— well has deduced the following law: "Regulate it been observed: "He who degrades a all of your actions in such a manner colleague degrades his art." that the highest end of your calling, "In changing from one physician to which is saving life, restoring health another it is common for patients to Some well known rules will be reiter- ated for emphasis, which seem especial- ly to tend in their strict observance to smooth the asperities of the profes- sional pathway. Such heritages from the wise, as well as the written evidences of lofty ideals frcm our profession, who, dur- ing the ages, have held aloft the Ca- ducieus of Hermes, are sometimes over- looked in the cares and drudgery of pro- fessional life. Some, therefore, are to be found, with heads more or less burdened with scientific acumen who show unpardon- able ignorance of their duty to the com- munity and to the profession to which they belong. Such one-sided tendencies can but be deplored. In a classic address on the relation of the physician to the public and to his colleagues, delivered at Oxford in 1846, Dr. Huefland said: "An instinc- tive impulse to relieve a sufi'erer was the origin of the healing art, and to and relieving the sufferings of human- ity may be attained as far as possi- ble." The subtle influence of one in- spired thus is a benediction to both the public and to his profession. The lamented Dr. Osier said in ref- erence to the public: "There is a de- lightful Arabian proverb, two lines of which run: 'He that knows not and knows not that he knows not is a fool — shun him. He that knows not and knows that he knows not is simple — teach him.' It is our province to have to deal with the extremes of civic life. We must fight the wilful ignorance of the one, and the helpless ignorance of the other. Not with the sword of righteous indignation, but with the skillful wennon of the tongue. On this ignorance, the charlatan and the quack live." attempt to justify their course by speaking ill of the former physician. No physician should permit such crit- icism." The porcupine attitude towards other physicians and petty quibbling only fur- nish material for jocose remarks from the public and add nothing to a voca- tion which holds a sacred trust. Dr. Cathell has well observed: "The great God of Heaven has declared: "What- soever a man soweth that shall he also reap' — any one upon whom you en- croach in an unprofessional manner will feel himself justified in retaliating with your own weapon, and you will reap a crop similar to the seed sown." Whenever you sow a thistle or thorn you will reap thistles or tho^^ns, when- ever a wind is sown a whirlwind will be reaped, whilst the sweeter June. 1922 ORIGINAL COMMUNICATIONS 279 sown by others will yield sweeter fruit." Compared with the revenues from other vocations, to the great majority of the medical profession the remun- eration is pitiably small, especially when the grave character of the ser- vice is considered and the exacting de- mands it entails. Necessity demands that the business side must be looked to, not truckling to wealth, for this only furnishes op- portunity for gibes from the factious scribe — many years ago the great Bard observed: "The learned pate ducks to the golden fool." To some this may appear a warranted accusation, but to the real physician, "What is a handful of gold compared to the tears of grati- tude shed by the poor who, unable to speak or give, pours out a confession of eternal indebtedness, while the rich man often believes himself redeemed by payment of all obligation of thank- fulness." Whether due to that innate instinct, previously referred to which leads one, or to the subsequent intimate association with humanity unmasked by the joys and sorrows of life's dra- ma, "fhe tense moments which mark the climax of exultant joy, or the pathos of abysmal sorrow — certain it is that the physician, excepting the im- placable mercenary whose ultima thule is the paltry dollar, occupies a stratum of unselfishness and altruism above the average man. To one donning the toga of Aesculapius, especially where the role of general medicine is assumed, the temptations of social life and the lure of society, in the main, become the music of Sy- rens, to which a deaf ear must be turned. On the other hand, the cry of anguish or the moan of suffering and the prevention and relief of hu- man ills always demands precedence, commanding time, ability and skill. The recompense comes; not from social tri- umph, or the fascination of toying with the power of Mammon, but from that source of most genuine pleasure, viz., the consciousne>s that in preventing and alleviating suffering his talent or talents are being used to the best ad- vantage and that he is contributing his full quota to the progress of the race and towards the promotion of the hap- piness of others. Whatever the ability and training when that complication of the physical and the psychic which constitutes the mechanism with which we must deal, with the many unknown elements which enter into that problem of prob- lems, human life — baffling often in their subtleness those best qualified by education and natural capacity, is it any wonder, especially when under most unfavorable circumstances a hasty judgment is imperative, that the proper value of the X is not always reached? The exalted ego is suggestive of a phychosis. It is safe, therefore, to pos- tulate that the normal mind recognizes many mistakes; some of which may remain deep and lasting sources of re- gret. To exploit such misfortunes in oth- ers, is an unwarranted assumption of infallibility, is unjust and stamps at least as narrow the one so doing. Should the incentive for such unkind criticism be retaliation, it will be well to recall the cogent words of Milton: "Revenge that first tho' sweet. Bitter ere long back on itself recoils." MaCauley has well said: "No re- ports are more readily believed than those which disparage genius and soothe the envy of conscious medioc- rity." Envy, jealousy and malice, at- tributes of the weak and vicious, are never steps to professional greatness, neither can the wreckage of character of one's confrere be converted into a ladder to professional heights. Disparaging allusion to the ignorance of the past does not commend one, for the world knows centuries were requir- ed to produce one Hypocrates, a Jenner, a Pasteur and a Sims, not to mention the few great now living, and that the vaunted perfections of today will be viewed by the medicine of the future much as we contemplate prehistoric man's stone axe. It ill becomes one — granting "all the - 280 SOUTHERN MEDICINE AND SURGERY June, 1922 world's a stage" — during the few ticks are securely won, not resting alone on of the clock that he occupies the center humanitarian or idealistic grounds. Its of the footlights, to depreciate the ef- far reaching achievements from a hu- forts of another, who is just emerging man progress and economic viewpoint from the Eastern curtain, or of another can not be questioned. The limitation, whose lengthening shadows presage if not the practical elimination, of Asi- that he h cbse on the "hindmost wheels atic cholera, typhus and typhoid fevers, of Phoebus." diseases of children, diphtheria, bubonic The opinion of the public, in matters plague, smallpox, yellow fever, hydro- relative to which it is in position to phobia, etc., the records of which fur- know little, is formulated and moulded nish the most gruesome pages in the by the attitude of such representatives history of man, establishes our position of the class with which it comes in in the minds of the reasonable. And contact. It would be an illusion, there- the saving by surgery of life, limb and fore, to assume that the impression of function during the great war furnishes the profession in general could be ex- a new chapter of marvels convincing to alted in the public mind when some of all but the deluded followers of strange its votaries do not avoid the semblance Gods. of mysticism; that they do not secure The above animadversions have ref- the co-operation of their intelligent cli- erence in the main to the derelictions of entele by candid explanations and in- medical men. Yet the laity bears no structions whenever feasible; that they negligible part, by misleading if not voluntarily catalogue themselves with false statements, as a causal factor of Doan, Tanlac and others of nostrum no- discord among the ranks of the profes- toriety by permitting their names to sion. be made trade-labels for pills, powders Gratitude, the highest reward for or lotions, thereby contributing to the service, is more or less discounted as armamentarium of a class of distinct an asset by the veteran. To those hold- violators of the law, viz., prescribing ing the view of Brook: druggist — actuated either by' well meaning complacent ignorance or sor- "If there be a crime did motives — in either event proving Of deeper die than all the guilty train insiduous enemies to humanity. Of human vices, 'tis ingratitude." Another Judas sometimes exists who falsifies symptoms to promote surgical A shock may come, for the physician fees; or still another, who takes advan- is fortunate, if he never recognizes tage of the beneficent effort of health among his most l;ruculent critics, some boards, looking to the reduction of for whom he has made sacrifices and deaths from diphtheria and other dis- contributed his best efforts. There are eases, by furnishing free serums, etc., rnany modest doctors who after jeop- and yet disposes of such, often in spur- ardizing life in storm and flood have ious cases, for his personal gain. And single-handed faced the grim monster, far worse that some, prostitute their ^"^ by that fight have stayed his prog- vocation and under an honorable flag ^^ss and saved one or perhaps two lives, enter into clandestine compact with no ^^ wears no Carnegie hero medal — not less venal surgeons in order that, in the ^^ — often he doe« not receive the pit- language of their bolder though less tance of a fee for his great service, hypocritical brothers they "may 50-50 Apropos to the above, that modest the swag" or "whack the loot," not to man and graceful writer, Ex-Vice-Presi- say fee, thus surreptitiously extorted dent Thomas R. Marshall, in an article from their trusting and unsuspecting presenting his philosophy of life, paid patients. a classic tribute to our profession in his Such de-^nicables are foul spots on allusion to his own father. I will take the Escutcheon of a profession of no- the liberty to quote in pa:-^: ble aims and attainments. Its laurels "Early in life he learned that it was June, 1922 ORIGINAL COMMUNICATIONS 281 possible to be great in a number of ways and also that success depended upon the personal viewpoint. I had four un- cles who went into the Union Army dur- ing the conflict between the North and the South. Each rose from the ranks to a captaincy. Three of them died as the result of wounds received in that conflict. My father was physically un- fit for military service. During all that long and awful conflict, in the malaria- infested districts of Northern Indiana through scorching summer days and bitter winter weather, he followed his calling, ministering to the sickness of the wives, widows and children of those who were at the front, and refus- ing all compensation therefor. He con- tracted the disease which finally led him to the gates of glory, by riding in the face of a storm blowing fifty miles an hour with the thermometer twenty degrees below zero to act as patron saint at the birth of a soldier's boy in a log cabin where a pail of water froze solid on the side of the bed away from the fireplace To "all the other members of our family my uncles were heroes and greiit men, my father just a commonplace relative. But to me he was the great man, and to this day I would not exchange his old medicine chest for all my uncle's epaulettes and spurs and swords." The Physician's Responsibility. From the physician the public has a right to exact efficiency in diagnosis, treatment, and prophylaxis. To meet these requirements every available aid must be invoked to properly interpret the intricate symptoms at times en- countered, not forgetting that abstract science is nothing unless it be the hand- maiden to an analytical mind, common sense and sound judgment. And per- haps something else. However genius may be defined, certain facts stand con- spicuously out. That ambition, energy, persistency and knowledge of colors are not sufficient to create a masterpiece in art — that the poets whose work bears the stamp of everlasting life make a short list, that music has few stars — that to the genius of Napoleon, Foch gave credit for his recent con- quest; that inventors whose names are immortal are rare; that study of the national game and practice by millions have produced one Cobb, one Speaker, and a Ruth ; that the trap where sight and instant co-ordination are essential, have furnished few over 95 per cent shots — that in sidereal observations ap- proach to accuracy varies with the in- dividual. In other words, study and training serve to reduce the personal equation, but few indeed have the es- sentials to entitle them to a place in the Hall of Fame as diagnosticians. The human body is not alone a culture medium or incubator for micro- organisms, a chemical retort, but the domicile of that elusive phenomenon, life; and in its highest form dominated by that even more evasive and enig- matic complex, mind. That cold ma- nipulator of men and master of poten- tial psychology. Napoleon, wrote ^ "Im- agination rules the world;' and he is blind who does not realize that in mor- bid states it is no negligible entity. In disease occasions arise where the in- spiring influence of confidence — a reas- suring voice or other tokens of personal interest and sympathy, are worth more to the suff'erer than all the valued aids of cold science combined. Therefore, unless insurmountable barriers exist, the wish of the patient should be law, in the selection of the consultant, after the advisability of such has been im- pressed by the attendant. Medicine, having outgrown individual capacity, co-operation has become a ne- cessity. The physician is unfortunate who cannot have easy access to the more important specialist, as well as to the competent laboratory technician. Group medicine ideally, seems to meet all demands, while it eliminates most of the objections to individualism, its general adoption might tend to fos- ter a more serious class antagonism; it might supply a buoy for incompe- tents and nurture a spirit of commer- cialism, whereby the public may be un- justly taxed and the profession dispar- aged in their estimation. That this is not impossible, quite recently a lady of small means was referred to the dental 282 SOUTHERN MEDICINE AND SURGERY June, 1922 surgeon of a group, rather high on the to be of value. ,^, ^ ^, ui- Mount McKinley of medicine, for the First, we will note that the public removal of an outlaw tooth. By mis- weal as well as the determination to chance she saw the diagnostician who, purge the profession of the unworthy after sending her down the line for in- dictates, that those cognizant of viola- vestigation, reviewed the findings, and tions of the law, intended to regulate the after an assessment of $240.00, inform- practice of medicine, shall take positive ed her that she had a tooth which must legal steps towards the punishment ot be removed. the guilty. The crucial test for all conduct— the Emergency Cases. one law, which regardless of creed or Reference will be had first to them as religion, all philosophers and prophets there is no more fruitful source of va- acknowledge as paramount in determin- riance. Article IV, Section 5, of "Prin- ing and governing human relationships ciples of Ethics" contains this which from a social or economical viewpoint should be constantly borne in mind: is the Golden Rule. Make it the stand- "When a physician is called in an emer- ard of measurement for every act; the gency and finds that he has been sent court of last resort — the final tribunal for because the family attendant is not for every doubtful position, and error at hand, or when a physician is asked will not occur. to see another physician's patient be- Yet delicate situations present them- cause of an aggravation of the disease, selves, in which specific rules prove of he should provide only for the patient's service in preventing friction between immediate need and should withdraw medical attendants and by harmonizing from the case on the arrival of the fam- action serve for the benefit of the pa- ily physician, after reporting conditions tient. found and the treatment administered." History. Even where there is no family physi- Hypocrates was perhaps first to recog- cian, never be tenacious of doubtful nize the necessity of such rules and rights. Where called in emergency, ask furnished a system of laws for the gen- the direct question and if another eral government of the profession, was preferred, and you were not delib- "This code served until Dr. Thomas erately chosen, surrender the case to Percival, an English physician, in 1807 him ,even though asked to continue the published an admirable Code of Ethics case." If your conduct towards other which, except such alterations made physicians is invariably honorable and necessary by the lapse of time and the just it will be discovered in due time advancement of medical science, is the and will make your road pleasant, identical code adopted by the A. M. A. and if you ever unwittingly infringe all in 1847, and from then to a few years will feel that it is through mistake and ago has governed our whole profession, not intentional." just as the Ten Commandments of Holy "When called to a case previously Writ instruct and restrict mankind in treated by another physician, especially general." With slight alterations this if patient and friends are dissatisfied is incorporated in the "Principles of with the previous attendant, never ex- Ethics," the present law. press a wish that you had been called Copy of the same, as well as answers sooner, or criticise his conduct or reme- to any mooted questions of Ethics, may dies — it is mean and cowardly to do be secured by writing to Secretary either." Notes and Queries Journal A. M. A. Never take charge of a patient un- Chiefly for the sake of emphasis, the der care of another physician without writer will quote some paragraphs from first ascertaining that he has been for- "The Principles of Ethics," which bear mally notified of the change, otherwise on som_e of the most common causes of unless great emergency exists, you misunderstanding and mention some should positively refuse to interpose. If collateral rules or customs which seem you consent it should be done for the June, 1922 ORIGINAL COMMUNICATIONS 288 attending physician, and you should have one of his own patients cared for leave a sealed note telling him what under similar circumstances, you have done- "Suffer injustice rath- The patient should be returned to the er than participate in it." care of the attending physician as early Travail, proverbially problematical, thereafter as possible Obviously under often places itself in the emergency such circumstances, for the emergency list. Contrary to the rule in other physician to prescribe a line of treat- emergencies, courte.sy does not dictate ment to be continued would be a flagrant that the fee for the accouchment be ^'^^ f^^«\f ^^e spirit of the law. turned over to the regular attendant. After thorough consideration of the However, he should be promptly noti- 'arge accessions to those posing as spe- fied of conditions and the after treat- cialists, often of the Correspondence ment of the case left to him. Consul- School variety, the pronounced senti- tation.s-so far as the attendant is ment of the A M. A. favored a course of concerned, the disarming of damaging three years of specia work, before any criticism, is a desideratum but above physician should be eligible to be called all-in consultations the welfare of the a specialist in any line of medicine, patient is the highest thought, and Such requirements would serve to as- every physician should be penetrated ^ure the pub ic that in his branch the by this simple sentiment. specialist, at leasf would be better quah- T.^L. ^ ^ • • fu^ .^...„ifofion fied, than the average general practi- What transpires in the consultat on ^^ ^^^ ^^^.^^.^^ .^ ^^^_ room should be held as inviolable as the ^^^^ ^^^ ^ secrets ot the patient acquired as here- ^.^'^^^^^.^^^^ ,1 ,,ith the excep- sult of the ^""fif^".^^;;"^P°^f^/" ^^,^ tional emoluments that pertain thereto, medical f endant. If thou hast heard ^^^^ ^^^^^^ ^^^ ^.^^ ^^ competitor, per- bu^S^'^'t : .'' ^Th:" o s tarl?u?d ^^Ps sun-eptitiously with specialists in sedulously avoid -king radical ^l^^:^^:^^^^^^' changes in treatment unless imperative , f. ^ .,. „ v.^fv^n,\. ^^r.^, , J 1 u f,- ,^. fZ^ f^ fV.o der ine cases. Well, we refrain from demand leaves no alternative for to the . . ,-. • „„•+>, \,io . , , . i.;i . ^f comment except to say, it is with his ay mind such a course is susceptible of ^ . j u !i- j ^ „ \^^\ . . , ,. conscience, and when the end comes, but one interpretation. .. -^ ^u- * i ■ » , , , • -^ ..u sit tibi terra levis. The consultant should not visit the j^ -^ ^^^ ^^^ ^f pl^^g ^o note that a patient, except with the attending physi- ^^^^^^ honored by time and the best cian, unless by special request of the authority— in deference to the mutual latter. If unexpected circumstances ^^^^^^^^^^q of one physician on another, arise the attending physician may vary ^^^. ^^^.^ther physicians to extend a grace- the treatment; not so tne consultant, ^^j courtesy, during a physician's tem- except in extreme emergency or when ^^^^^.y absence from sickness or other called from a distance. In that event a ^^^^^^ ^y ^^j^j^^^ ^^^.^ of j^ig ^^^k, and .sealed statement should be left for the ^^ ^j^ j^gj-^^.^^ ^^ service turn over the attendant. A physician should never patient and the fees for service render- take charge of a case when he is con- ^^ ^^ ^^^ g^ ^^^ ^g ^he fees are con- sultant, except at the request of the at- ^erned, this is not obligatory, yet it tendant. Some specialists seem forget- ^-^^^^ ^^^^^ f^^ magnanimity which will ful of Article 3, Sec. 4 of the Principles j^^ reciprocated. Things done, not per of Ethics. Colleagues patient— Article f^^.^^ ^^.^ ^hat make the amenities of IV, Sec. 7. When requested by a col- jj^^ ^^ Cathell says: "There are a league to care for a patient during tern- thousand unwritten ways to be ethical porary absence, or where, because of ^^^ ^ thousand undefinable ways to be emergency, he is asked to see a patient unethical." Physicians are no longer of a colleague, the physician should aesthetic porcupines hedged about with treat the patient in the same manner points of etiquette bristling in fretful and with the same delicacy as he would expectancy, but are controlled in their 284 SOUTHERN MEDICINE AND SURGERY June, 1922 natural relations by their instincts as amiable gentlemen and governed by the dictates of common sense. Courtesies in many forms may be extended which tend to engender mutual regard, a deep sense of personal gratitude and lead to the warmest friendship." The atavic coming from savage ante- cedents, that tendency to resent by vio- lence injuries real or fancied, in man, is conspicuously manifest in the child and the moron, yet occasionally gets possession of those whose volitions are subject to intelligently governed will. Allusions to the paths of peace or suggestion as to higher standards of liv- ing, to some seem visionary and elicit only a derisive smile. Such persons, supine in the fight for better conditions, are but miserable barnacles on their craft; obstacles slightly impeding the influence of the great motive power to- wards the right, and add nothing to their profession or country. The his- tory of all truly great is the record of ideals vitalized and consummated. The word pacifist during the great war was tantamount to if not synony- mous with slacker. Today those whose voices are most powerful in advocacy of peace do not represent the slacker class, but on the contrary, they are the fighting men, the greatest generals, who stemmed the murderous tide of battle and who by personal contact real- ized the full meaning of brutal conflict — war. The time is passing, if not now his- tory, when a nation or an individual must needs be weighted down with life destroyers — when the citizen must wear a coat of mail and carry a sword and spear to maintain his property. Yea, even the sanctity of his home. Throughout the civilized world the Sculptor's art has been taxed to con- tribute pretentious arches and imposing bronzes commemorative of deeds of blood while but few simple slabs have been dedicated to peace. Perhaps the first arch to peace has just been erected on the great Pacific Highway at the international line in honor of a century of peace between the two great nations of North America. This may signify the beginning of a new era. With the paint still moist on the can- vas which depicts that fearful tragedy, that long premeditated attempt at domi- nation of the world by brute force and the refinement of atrocious frightful- ness and while humanity in every land is staggering half dazed from the enor- mity of the blow which destroyed seven- teen million lives; and while enormous burdens and blasted hopes are crushing nations, and thousands upon thousands of cripples and starving children are ghastly and pathetic monuments to the worship of Mars, with clouds of chaotic import lowering and politicians whose red flag is League of Nations or (?), wrangling and quibbling over "Tweedle dum and tweedle dee," and diplomats playing the cards for gain; philanthro- pists and statesment are laboring to forever rid the world of the ideals and customs which mean contempt of the weak, the arrogation of might or mur- derous vengeance — war. Let those rep- resenting the most altruistic profession be first in the cause of humanity, and as a profession, "in scorn of miserable aims that end in self," determine,, in- spired by the spirit of Lincoln, to "go forward with malice toward none, with charity for all, with firmness in the right as God gives us to see the right." To the end that our benfactions may be extended and that it may justly merit this encomium — "The most sublime vo- cation of man often is that of being high priest of the holy vital flame and administrator of God's highest gift and the most secret powers of nature — in a word, a physician. Discussion Dr. E. T. Dickinson, Wilson, N. C. Dr. Furman has, I believe, spoken de- liberately, distinctly and righteously. I believe that this subject is the most im- portant subject that has yet been before this house. I believe that the old code of ethics was written from the wrong standpoint. I believe in this day of specialists and this day when we have vast opportunity for the benefit of hu- June, 1922 ORIGINAL COMMUNICATIONS 285 manity it is time for a new code of "This is too ridiculous to let go by, to ethics^o be written, or, at least, for the say nothing of the justice, somebody old code of ethics to be forgotten. ought to go," so this doctor did have the I persued, as best I could, this highly conscience that I thought and went. <.cientific and technical paper, and com- When he got there the people were so pared it to conditions we find at home, enraged that they would not let him and there is no semblance of the princi- come in to warm his hands, pies of this paper in what we find to- It is ethical to refuse to go out at night day at home. There is nobody object- to see the sick and diseased if it is a lit- ing to this old principle of ethics that tie over the line. On the other hand I throws a stone wall around the doctor find various communities where doctors for his protection, not the patient's, and charge in the daytime in inverse ratio everybody goes along in this day work- to the distance. They charge $2 or $3 ing for the benefit of the patient, re- for a visit in their own town, but if it is garding very little the ethical effect of to go out eight miles they charge $2.50 his right arm or his left arm. or a little more. The medical profession is in this day, ^^ ^^^^^^ ^ Richmond, Va. one body. We meet monthly and week- ly, and here annually. We are gone half When I saw Dr. Furman's title on the our time to these associations. We rub program for this meeting, I was worried up against each other and we are not because I thought he would bring up going to do each other any great injus- ethical questions which might cause tice — no gentleman i.s — and if perchance trouble. one does fall from the high plane of a The Tri-State Medical Association is gentleman, he will be gradually pushed not a national organization, nor does it aside by the profession even represent one of the three states " There i^ not any family doctor these f^ojn which its membership is drawn, days. If there is, he does not stand up and therefore a discusion of ethics and claim to be a family doctor. The ^^ff l^ad to no definite results. old lady has one doctor for her trouble, ^ After hearing Dr Furman s paper, and the old man has a certain kind of however, I am delighted^he has read it. trouble, and he calls his specialist, and He has taken as his text the Golden Rule the children, each one, calls his own doc- f "^ preached one of the finest sermons tor these davs. There is no way of dis- ^ ^ave heard for a long time. His paper criminating 'as to family physicians. !^ ^^I^ssi^ ^" ^^s composition, practical m The old ethics is entirely out of style, in ^^s conclusions and has, I am sure, been many ways and is disregarded. a great benefit to all of us and I wish to ^ . , ^ , T , , thank him for it. Coming down to home, I want to men- tion a concrete example. It is ethical in Dr. A. B. Patterson, Barnwell, S. C. my community at night for a man to ^j. President, this is a question which ride in on a mule, after he uses all the j ^ave been for years interestd in. telephones he can. It is ethical for years ago I did read the medical code every one to say he is sick, because he ^f ethics, but I have forgotten the says it is a little bit beyond the midline articles in that code. I don't suppose between this town and the next. He ^^at there are many present here who thinks it belongs to the other town, so have ever read it, and if they have read he sleeps on because of that question. jt jt has never amounted to much with A few weeks ago a man came up to them. If there is any one thing that he my door on a mule, asking me to go see cares less about it is that code of ethics, his wife, said he had been two hours I am satisfied that it has been a great riding over that town in the snow to stumbling block to the profession, get a man to attend his wife in labor. We all know, Mr. President, that to- I had a good excuse, and I called a doc- day the government, both national and tor that had some conscience. I said, state, is interested in public education. 286 SOUTHERN MEDICINE AND SURGERY June, 1922 in educating the public mind upon medi- this paper it would be this— that a dis- cal topics. I say the great drawback to cussion on the question of medical ethics our profession today is the code of ought never to be made before an adult ethics that prohibits a man advertising audience. It ought to be made before what he can do. A man may spend his children and very immature children at money and time in hospitals gaining in- that. Ethical recititude is a part of formation on special lines, but when he character and character is made in returns home he has no medium by early years. which he can give to the public and let i frankly say that it never took any them understand what he can do and ethical code to make me do the right what he knows. He depends upon his thing, and it never took any law to make colleague largely through reprints, with me honest. Honesty and right dealing a view of attracting his attention and if not hereditary were taught into me getting his co-operation. That amounts early. A man who is honest no further to very little. The gentleman who read than the law compels him to be is dis- the paper today spoke of the/anvy, the nonest within; and a man who is ethical malice and the maliciousness in the pro- only because the Code forces him to be fession, and I have had my share of it, ethical is not much better than a scoun- as we all have had. drel. In other words, if you are born Who ought to judge of the qualifica- white and reared white, you are white; tions of the family physician, the public, and if you are not, you are not white — the father or the mother? Are they that is all there is to be said about it. judges of the doctor who comes in to It is like the question of sobriety; some treat the baby? They have no way in people cannot help getting drunk, and the world of getting at that man. They others will stay sober. They were made don't know whether he is treating it that way. The sober man need not wrong or right. He calls in a consultant boast over the man who gets drunk, but who is more or less aggrieved but ques- he can humbly just thank God he was tions his judgment and profesional made out of a little better stuff, standing. Very often I have found out i never thought, however, that the that when I have had a consultation code was a stumbling block to any gen- wdth a doctor and suggested anything tleman in the profession. The code is in opposition to his treatment that noth- but the golden rule. I know when my ing had been carried out that I had neighbor treats me right, and I know suggested. What are you going to do when I treat him right. If I dont' treat with this state of affairs. him right, really I suffer more than he We want the only ethics that we does; because any man who does in- should have, that is the golden rule and iquity suffers his iniquity more than that standard that all must live up to the man against whom he does the in- that call themselves gentlemen. Now, iquity. all men are not gentlemen, and all men ^^at my friend says about advertis- are not well bred. I am speaking of the ing,_I never would advertise. One day profession or we would not have that ^^ insurance man came to me and said, statement here today of this jealousy «You don't do much insurance examin- ^"^ ^^"^y- ing." He said, "Why don't you?" I I believe there should be a way, when said, "I do all that comes my way." He a man is accomplished on any line that said, "If you will ask the agent for it, there ought to be a medium by which he will give you more of the work." I he can get to the people who need it. said, "I wouldn't do that; you don't The most successful physicians I have know what kind of a Scotch-Irish man I known have been the most ignorant men am. I would eat bread and water before I have known on that question. i would advertise or beg for practice." Dr. Cyrus Thompson, Jacksonville, N. C. I am proud to be a doctor. If I were If I have one criticism to make on a lawyer, I would not be a shyster. If I June, 1922 ORIGINAL COMMUNICATIONS 287 have qualifications, I need not tell them, the kind of thing that he said should "A workman is known by his chips." not be done, such as speaking against "If a man preach a better sermon or the past and the statements of col- write a better book or build a better leagues in the past — not to speak of mousetrap than his neighbor, though colleagues speaking in the present — but he live in the heart of the wilderness, later. I began to think, and I focussed the world will make a beaten track to my thought on the question. My thought his door." I always feel that way about was that although guilty, what are we myself. In fact, I was never stuck up, going to do when we come across in but always wonderfully proud. I hope writing or in practice doctors' state- no man in this audience would think of ments which we believe to be funda- advertising, like the chiropractor and mentally false and wrong? Are we to the osteopath. We are better than that, sit silent because of the fear of offend- If I mistreat my fellowman, I know ing a colleague? My answer was No. I have done it. If he mistreats me, it We are scientific men, as well as being does not harm me. I remember that practitioners of medicine, sweet saying of the psalmist, who said. Some of us who are engaged in try- "I have been young, and now I am old : ing to find out the truth about matters yet have I not seen the righteous for- concerning which there is not yet a saken, nor his seed begging bread." Let decision, feel we must speak what we us be right— which is straight— and be think is the truth about these matters, content with the honorable portion of That I have done, so that my feeling of the righteous. guilt greatly passed away, although it The absolutely ethical man doesn't had been quite strong, have to advertise, and, really, he doesn't i should like Dr. Furman in his reply want to advertise. He doesn't want to to try to differentiate what in his mind do the other fellow wrong. If a man is the line with reference to what we does him wrong, let him go on right and shall say and shall not say about the catch a clear vision. There was a big ethics of the colleagues-it is a scien- Baptist meeting and everybody was be- tific question, ing immersed. Great waves of salva- a .u +/ v,^ tion were flooding the land. Two little ,^^-'''^'' '^%"f ^ '^"^^ 'T' ^ T^ waiL^nrtrie^tTgrhirunr ut -t depend upon scientific medicine, but they could not. If ?hey immersed one "^^ ^^^k^^' ^-^-^ ^he public, part another stuck out. The goat was ^^^* ^""^ ^® ^^ ^° ^^°"^ ^^- ^^^^^ recalcitrant. "Let's baptise him as far ^^^ ^^^ reflections that came to me in as we can and sprinkle him the rest and '^^tening to this beautiful statement call him a Methodist— he isn't anything ^^^"^ ^^^ ^^^^^^ °^ medicine. The code but a goat and he is going to hell any- 1???^^ "P°"' ^^^ ,^^^^^" ^"^^- ^^ ^^ way," think right about the other man we are They finally worked themselves out of ""^^^ ^^^ ^^ ^° ^^^^^• breath, trying to make straight land Dr. Furman Closes Discussion of Paper. save a crooked thing, when one of them t • i • ^ ^u i ^i . . panting said, "Hold on, buddie, we ju^ .-^ '^^J^ '''' '' '^^f those who have can't do it." discussed my paper. I really didn't ex- p. . „, , ,^ „ pect to start such a big cyclone when I Dr. A. B. Patterson, Barnwell, S. C. presented the paper. I never advertised in my life. I never in regard to what Mr. Thompson savs advocated advertising, as he said, as the as to having no rules. Congress and all osteopath and that class of men do. other organized bodies must have rules, Dr. Tom A. Williams, Washington, D. C. not because they are unruly, but rules When the doctor started his paper I are essential to preserve harmony and begun to feel very guilty that I had done efficiency in any line of endeavor. 288 SOUTHERN MEDICINE AND SURGERY June, 1922 THERAPEUTIC IMPRSSIONS* By Ivan P. Battle, Rocky Mount, N. C. One who leads the life of a general practitioner, who must gain his liveli- hood from his profession has but little time and less inclination for careful records. However well he may practice he adds nothing to the science of medi- cine. He follows more or less blindly the leaders of his day. Nevertheless, by reading and observation as the years go by, he accumulates a vast number of ideas and opinions on various subjects; ideas that cannot be reduced to definite conclusions by the use of statistic run- ning into the hundreds and thousands. These ideas of the general practitioner are best described by the word "impres- sions." During the past year many interest- ing papers on drug therapeutics have been published. A reaction has set in against the therapeutic nehilism of two decades ago. Spurred on in part, I fancy, by the mushroom growth of drugless healers that has sprung up about us, doctors have begun to take a deeper interest in their patients than the pathology they might show. We are in the beginning of the age of chem- istry in medicine with hope of many brilliant discoveries in the future. Al- ready those of us who graduated fifteen or twenty years ago, and have been doing general practice feel ourselves left far behind. In this paper I have nothing new, nothing original to offer,' but because many of you like myself are general practitioners I thought it might prove of interest to give some of my own im- pressions of drug therapeutics. To me the greatest disappointment in the study of medicine came with the disallusionment that the study of drug therapeutics brought about. Beginning the study of medicine with the idea that there was a curative drug for nearly *Read before the Tri-State Medical Associa- tion of the Carolinas and Virginia, Norfolk, Va., February 22-23, 1922. every disease, I came out of college with the specific counted on the fingers of one hand. All the other diseases fell into three general classes: 1st, Surgical ; 2nd, Hopeless ; 3rd, Self limit- ed infections. Morphine was the treat- ment for the hopeless; and "expectant symptomatic" was the term by which the treatment of the third class was de- scribed. I knew nothing of the art of prescription writing and there was no incentive to learn. It seemed that there was nothing for the general practition- er to do but to treat itch, worms, and chills and make a diagnosis of other human ills. Established custom and public demand forced me to use drugs often when I would have preferred not, consoling myself with the words, "Medi- cine sometimes cures, it often relieves, it always consoles." Out of this limited experience coup- led with the reading of the writers on the subject I have grown to rely on a limited number of drugs, some of which I wish to mention briefly today. Of the long list of heart stimulants of my student days two remain, namely, camphor and digitalis. Camphor is the stimulant of choice in acute infections unless there is a previous chronic myo- carditis when digitalis also would be in- dicated. In the absence of chronic myocardial changes McKenzie states that digitalis is worthless as a cardiac stimulant in acute infections. On the other hand I believe camphor has pulled some patients through acute infections when without it they would have died of heart failure. Of digitalis so much has been written in reecnt years that it is hard to find a paper with anything original on the subject. The greatest emphasis has been placed on dosage. The so-called Eggleson method of ad- ministration cannot be carried out by the general practitioner. We have to feel our way with the dose, but all of us have been guilty of giving too small a dose and expecting results. The dose of digitalis in the hands of the general practitioner is determined by the reac- tion of the patient to that particular preparation. When we consider, how- Juno, 1!) ORIGINAL COMMUNICATIONS 289 ever that by the cat unit method the when giving cinchona or rather its alka- equivalent of 5 1-2 drams of potent tine- loid quinine to a known case of malaria, ture is given at one time intraveniously We know that here we have a specific to an adult weighing 150 pounds, the remedy for the disease and yet its com- old dose of ten or fifteen drops T. I. D. plete eradication by the use of quinine seems ridiculous if a rapid digitalis ef- is not always a simple or easy matter feet is required Under such circum- Considerable has been written m recent stances I do not hesitate to give a dram years concerning the method of admm- of the tincture every six hours. Digi- istration and dosage of the drug. A talis while one of the most valuable agree that the patient should be well drugs of the pharmacopeia, finds its under its influence during the first few greatest usefulness in hearts with mus- days after the disease has manifested cular degeneration, particular in the itself or to use a lay expression until presence of auricular fibrillation. In the chills are broken. It is only the other words it is in the hearts of middle administration after the first few days life or after, that it yields its best re- of chills and fever that there arises a suits. It is of very little value, if any, disagreement. The older method con- in the ruptured compensation of valvu- listed in giving small doses three times lar lesions of childhood and youth, this a day for a considerable period. I have condition now being recognized as a re- seen such good results from this method infection of the old valvular lesion. In that I am not inclined to give it up but passing, I wish to mention one other believe that of giving large doses at m- drug that formerly and often now is tervals is of more value m cases of long classed as a cardiac stimulant, namely standing ^^^ere the treatment with strychnine. Though all of us use it in quinine has been but half carried out. one wav or another, still I am not cer- The outstanding drug m the list of tain that it has bul one value in medi- purgatives is the mild chloride of mer- cine, and that is to treat morphine or cury. To me, the giving of calomel m other depressant poisoning. alimentary infections means something Of the drugs used in the treatment of more than the mere emptying of the acute and chronic bronchial infections, bowels. It means that we are usmg a there are three upon which I place the drug which, dii;ectly or indirectly acts greatest reliance. These are the chlo- as the most efficient intestinal antisep- ride and iodide of ammonia and heroine, tic The time honored custom otgiv- The last of these, I believe, gives the ing bicarbonate of soda with this drug greatest rehef from the symptom cough i^ certainly justified from clinical ex- of any drug which we can use. The two penence only, I believe most of us use salts of ammonia, the chloride and too small a quantity of soda. Thir y • VI i. i. J ^.1, _ ^- or fortv grains at least, I think, should iodide, seem to me to deserve the most "^ ^'^^^y k^^ > , confidence as expectorants although the ^e used with a dose of six giains of conhdence as expectorants alt hougntne combined and followed in iodide IS usually classed with other ^^1""'*^^- '^y ^ .,., r^u-ji.t, 1 1 about two hours with a saline I have iodides. Combined they make a valu- '^'Juul l,^^u , • , 4? v^of,•«r.f 1 , • i.- • i^ • u i. seldom had a complaint from a patient able prescription in certain subacute or '^^'^u^i "'*'-' *; „ ^, chronic bronchial conditions, though ^^ unpleasant effects. they seem as often to fail as thev do to Of the salines, ordinary epsom salts produce the desired result. when a single dose is used, and cream of Now thP a IT ^necialist has lar^elv tartar in the dropsical condition, are my Now the G. U. specialist has largely ^ Recently I saw a statement taken the treatment of syphilis out of p^*=^«'^ ^ 1 j- • + v.v„-cf fv.of v,^ , , , --p 1 ^ ^-v, bv one of our leading internist that no our hands we have, if we exclude the '^/ ^'\^ ,. ^,,1.1 k^ o-,Sror, fn a J, . ^ ^ -I'-i-i.- 4^ 4-u drastic purgatives should be given to a treatment of paracitic infections of the '-"^f^^^ -.Z ^ a +^ rv,,.^oovri,-oi , . , ,• i^ ^ i. i_ i. natient with dropsy due to myocardial skin and alimentary tract, but one com- t}^\'^''^ "'^ ^ „;„«f„ „;v.o o,if r^f o J. , ' . . , . , lesions. I believe ninety-nine out ot a mon disease, namely malaria, for which "" . we have a specific. No more confidence hundred country doctors would rightly is ever experienced by a physician than disagree with him. Cream of tartar is 290 SOUTHERN MEDICINE AND SURGERY June, 1922 one of our most valuable aids in this other preparation in spite of the fact condition. Of the long list of vegetable that numerous manufacturers would purgatives and laxatives three seem to have us believe that an organic prepara- me the most reliable, namely, podophil- tion is the only logical way to give iron, lum, cascara and rhubarb. The question of why such a large dose At the head of the list of anodynes of iron, compared to the total quantity stands and always will stand opium, of iron in the body should have to be With it we can always count on the given, has, so far as I know, never been relief of pain of whatever origin. I have settled. often heard that doctors of the present What arsenic does mside the human day use opium, or to be more specific, body is as much a mystery to me as it its two alkaloids, codeine and morphine, was when I passed my exammations on too freely. I suspect with their quinine materia medica, and knew all about and Dovers powder the older doctors such things. Certamly the mystery were about as generous with the drug ^as complete at that time. Yet in a as we of the present day. The use of Purely empirical way Fowlers solution, codeine in small dose combined with arsenous acid, the more popular prepar- acetanilid or phenacetine and acetyl ^tion cacodylate of soda have seemed to salicylic acid certainly gives great re- "^^ usetul drugs. . ,. ^ i lief from the aches and pains incident I" recent years a new specialist has to acute infections, and when the disease ^^^s^"' ^^e Endocrinologist, a sort of is of short duration I think it not only distant relative of ours who has gone so justifiable but the very best of symp- ^igh on his tower of Babylon that he tomatic treatment. Certainly I do not ^Peaks a different language, but by believe I have ever made a drug fiend ^^ans of beautiful drawings shows us bv this treatment. Such combination exactly how to balance the internal se- oi- the drug requires a much smaller cretions. When lured along, perhaps, dose than would be necessary if it were ^^ commercial literature we attempt given alone. ^^^^ juggling act, we are forced to the „, ■]_■,-, , . . , conclusion that so far as the general The scientists have almost taken away practitioner is concerned the adminis- the need for the term diuretic in the ^^^^.^^ ^^ ^^^^^.^ .^ ^^ .^ deficiency strict sense of a drug that causes an m- j^ ^^.^^ ^^^^^ ^^ ^^^ ^^ ^^ ^^^ intelligent- crease of kidney secretion by direct j ^^^^^ pituitary extract and epine- action on the kidney tissue Itself. They ^^.^^ ^^^^^ ,^„ ^^ considerable use have left us but three,-theobromine, -^ medicine. heophillm, and caffeine and the reputa- Concerning new drugs I try to make tions of these IS none the best in their -^ ^ ^^j^ ^^ ^^-^ ^^^.^ ^^^^ competent minds. Theobromine with sodium sail- ^^„ ^^^ ^^^^^ ^^ ^^^^ The manu- cylate and theobromine with sodium f^^^^^^^ j^ constantly dressing up old ace ate often seem to act wonderfully ^^edicines with new chemical combina- well m increasing the quantity of urine, ^jons. Forshimer stated that the far- even when there is considerable evidence ther away from the mother chemical of damage to the kidney tissue Theo- ^^ey got the less active they became, phillm for some time has not been ob- j Relieve this is true. Of the new prep- tamable commercially and I have had no orations of recent years the most disap- experience with it. pointing to me has been benzyl benzoate. All of us remember that we never Heralded as the greatest antispasmodic could remember the long list of in- of all time, excluding of course opium, organic preparations of iron in our ma- it has turned out in my hands at least, teria medica days. Now I do not par- a miserable failure. On the other hand ticulaiiy care to remember but two ; the another drug that is of comparatively dried sulp/.ate and the iodide. For the recent date seems to me a most valuable secondary anaemias I have more con-|addition to our list of remedies. I refer fidence in the dried sulphate than anylto luminal. With it the attacks of Juno. 1022 ORIGINAL COMMUNICATIONS 291 epilepsy are controlled far better than and that is the only preparation of digi- by any other drug I have used. talis that is worth while, freshly pre- In making this rather arbitrary list pared. Strychnine is the best remedy of drugs I do not mem to convey the we have, but the administration of it idea that I am competent to pass judg- must be guarded, and I am certain that ment on the numerous remedies that we use strychnine in too small doses, as have been advocated in the treatment a rule, but that must be observed very of human ills. I am simply giving my carefully too. Give strychnine when in- own preference, a preference based on dicated, give it to the point of physio- impressions. Given this list and a few logical action. You will undoubtedly others I have not mentioned, I could get a better result from it than any practice my profession more honestly drug in the pharmacopeia, than I ever hope to do. Like all other j^^ ^^^ j^ Williams, Washington, D. C. general practitioners I am guilty ot using ready mixed prescriptions. I Of course physicians must be scep- think this justifiable occasionally. Often tical and not credulously accept what is it is laziness. Quite frequently they told them by interested parties; but m are placebos. Of one thing I am posi- such cases as these well observed and tive,theyalwavs help the manufacturer, carefully studied, when honest men tell us of the consequences they observe Discussion. ^^^^^ definite treatments we are not do- Dr. W. E. Anderson, Farmville, N. C. i^g our duty unless we pause, observe. This really is a matter of very mater- cross-examine, reflect and finally try ial importance. The therapeutic side of what these men place before us. For the practice of medicine today is not example: No one can aflford to try to only neglected, but very much abused, ignore the numerous observations con- particularly in regard to opiates, and cerning the effect of pituitary feeding, I really got on my feet to say that heroin of the fall of blood pressure when ovrian should be excluded from materia medica. substance is injected, of the clinical I come in contact every day with pa- consequence of the administration of tients — we are in touch with various adrenal substance, and this in spite of kinds — and heroin is the one now that the assertion of pharmachologists that they are sticking to. Quite a number the hormones of these glands are neut- of them know morphine is an opiate, ralized by the digestive juices, for that but not all of them know that heroin is no proof that the chemicals of which is. I would particularly advise heroin they are composed do not functionate not be prescribed. I know perfectly when absorbed. The clinical facts which well that it is easy to relieve pain — it are matters of observation cannot be is no trouble to do that. You can use a contraverted. hypodermic of morphine or heroin, or The interpretation is another matter, anything you choose. That is not the and it is presentations of observations way to cure a patient. I want you to like these that give us a sufficient var- think of curing the patient rather than iety of facts on which to base interpre- relieve the pain, and not let the patient tations. get the opium habit. • ^ ^ r» t, ... r., t^- Not enough of us are paying partic- ^r. Ivan P. Battle Closes Discussion ular attention at present to the direct I just want to state for Dr. Williams' therapy, that is, to get results from benefit that I was speaking from the what we are giving. Digitalis, for in- country doctor's or general practition- stance, I note particularly that he said er's point of view. It would be fine if give digitalis and watch the results. I had my friend Dr. Williams down there We prescribe tincture digitalis in 15 to make the diagnosis. I don't know or 20 drop doses and expect to get re- that they are not useful drugs, but I suits. We don't get it unless we watch simply don't know how to use them and increase that dose. I use infusion clinically. 292 SOUTHERN MEDICINE AND SURGERY June, 1922 As far as the other drugs are con- with a pulse of 85 to 100 is a frequent cerned I thought that I made it clear in occurrence. With such an elevation of this paper that it was a question of im- temperature in intra-abdominal lesions, pressions and not anything that I can the pulse rate is much more rapid. As prove, so while there is room for plenty a rule, the leucocyte count is not so high of argument I don't think it is necessary in kidney infections and does not fluctu- to go into details in a paper of this kind, ate so readily as it does in intra-abdom- inal ones, unless complicated with urete- ral obstruction. The low temperature and low leucocyte count in the gangren- POINTS OF DIFFERENTIATION BE- ous appendix is familiar to us all, but this is the exception and not the rule. TWEEN KIDNEY AND INTRA- The leucocyte count seldom, if ever, ABDOMINAL LESIONS* rises higher than 16,000 to 18,000 in acute kidney lesions unless complicated By A. J. croweii, M. D., F. A. c. s., of the with perinephritis, in which event, it runs extremely high. Nausea and vom- iting are far less frequent in the acute kidney, without ureteral obstruction, than in the acute intra-abdominal infec- A review of urology and its import- ^ions. They almost invariably occur in ance in the field of medicine calls for the the latter and occasionally in the for- study of the urine and all the pathologi- ^.^r. specially is this true in the begin- cal conditions found in the urinary and jj^g Qf ^he infection. -r, '^ 'j- ,^ ■ ; Muscular spasm and its location is of By means of the microscope systo- ^^.^^^ dinicalsignificance. It is practic- scope. X-ray and a well equrpped labor- ^„ ^^ ^^^^^ ^^^^^ ^^^ ^^^^ ^^ .^_ atory, an accurate diagnosis of diseas- flammation and is of greater significance ed conditions of these organs can be +i „„ • rru ^ ^^a-; f i ui J 1 ^ -^ , 1 ^-rr- 1- , 1 than pam. Ihe location of a palpable made verv definitely and differentiated . • • -^ ^ i • -. Zi, 1 • , j-i.- -. ^ tumor mass is significant only m a cor- from pathological conditions of the u i.- a i • ^.t. ,,.,.,. , roborative way. A large mass m the Crowell Clinic of Urology and Dernu tology, Charlotte, N. C. obdominal cavity in a very large per- upper abdominal region may mean dis- T '^ 1- i.1 ^^^" • , i-r.- ^,■ ^ ease of the gall bladder, liver, appendix, I realize the occasional difficulties of Sidney, or stomach. Pain elicited by properly mterpetmg both the acute ^^ percussion over the kidney is very and chronic abdomen^ They aften tax gig^ifi^^nt as well as that caused by the skill of our best diagnosticians but ^^^^^ ^^^^ ^he descending and trans- the majority of such lesions can be as- ^,^^^^ ^^j^^ -^ differentiating between certained by careful investigation. i • i j • 4. u • ^ ^ ■ rp, 1 1 ^- s- ■ ^ ^ kidney and mtra-abommal lesions. ihe usual explanation of mistaken r,., , . , , ,. . diagnoses between the intra and extra ^^^ ^'^"^^ ^^" ^^ eliminated by ure- peritoneal lesions is insufficient investi- ^^^^.' catheterization and radiography, gation. There is seldom any difficulty Patients frequently come to our Clinic in saying positively that a disease is or ^f^^^^, history of having had a number is not located in the kidney or ureter. ""^ ^^^^^^^ of colic for the relief of which The fever in acute kidney lesions is fi^^^^f^? ^PP^^dix had been removed, much higher than it is in an intra abdo- ^^^ "''" ''^^^^^^ drained, the uterus fixed minal one. The pulse and temperature °^.°f ^^ ^°^^ ^^^^j^^ removed without are out of proportion in the two con- ''^^'^^' ^^^"^ ^ ^^^^^"^ urological exami- ditions. In the acute kidney, chills and "f '°" "^^"'^ ^^^^ ^^°^'" ^^^ presence a temperature ranging from 103 to 104 °^ "reteral stone, stone in the kidney, , movable kidney, kinked ureter, pyelitis, *Rearl before the Tri-State Medical Associa- pyelonephritis, pyonephrosis Or hydro- tion of the Carolinas and Virginia, Norfolk, pyonephrosis. In some of these cases va.. February 22-23, 1922. even a urinalysis had been neglected. June, 1922 SOUTHERN MEDICINE AND SURGERY 293 Just here let me say that a careful which began two weeks previously, urinalysis, both chemical and microsco- On inspection the patient appeared pical, should be made in every case ap- under-sized and rafher poorly nourished. plying for treatment. This examination The abdomen was distended and very alone may be the key to the situation, tender to touch. Her expression was There still exists an idea that a few that of a very sick woman and one in leucocytes in the urine are normal. This great pain. Her temperature was 103, is erroneous. From a urological stand- pulse 90, leucocyte count 15,500, R. B. point, all leucocytes in urine, collected C. 3,500,000 and haemoglobin 75 per by ureteral catheterization, are pus cells cent. The tongue was dry and the pa- and pus cells indicate infection. Their tient was distinctly toxic. She was presence in the urine may not signify having irregular chills and profuse serious trouble, since they may have sweats. A large mass was felt on the their origin in the genitalia or urethra, right upper quadrant but it was impos- yet grave conditions, such as, tubercu- sible to ascertain whether or not it was losis of the kidney, pyelonephritis or kidney, on account of a pregnancy of kidney stone may exist with compara- about six months' duration and tender- tively few pus cells in the urine. The ness in the region of the mass. An X- same is true of hematuria. A few blood ray examination was negative for stone, cells in the urine may mean papilloma Her bladder urine showed many pus of the bladder, slight bladder conges- cells and a trace of albumin. This was tion or injury, or they may signify the key to the real condition. Ureteral nephritis, ureteritis, pelvic papilloma, catheters were passed and we found a nephritic, ureter, or bladder stone, kid- very large hydropyonephrosis on the ney tuberculosis, hypernephroma or right side and a normal urine coming hypertrophy of the prostrate gland. It from the left kidney. The tumor mass is only by a thorough urological investi- disappeared, the diagnosis was cleared gation that their cause can be determin- up and the patient spared an operation ed. which would have been very disastrous. Dr. Caulk, of St. Louis, stated in his The predisposing cause to infection in paper at the recent Hot Springs' meet- this case was due to pressure from a ing of the Southern Medical Associa- pregnant uterus. tion that he found in an analysis of 200 Abdominal pain is often very perplex- cases of renal infection at their Clinic ing. The typical pathological gall blad- in 1916 that a positive diagnosis had der, appendix, or kidney are familiar to been made in only 9 per cent of them us all but what about the atypical cases. before they entered the hospital, where- We believe that all patients having as practically 100 per cent of the pa- abdominal pain should have an X-ray tients gave definite evidence of renal examination made and most of them disease. Failure to make urinalyses was should have the ureters catheterized be- the chief cause of error. fore operation. The latter is no longer An acute inflamed appendix or a considered a serious procedure and can tubo-ovarian inflammation mav cause be done quickly. It is occasionally fol- pyuria but no one is warranted in ex- lowed by ureteral colic but this is easily ploring the abdominal cavitv for either controlled by giving a hypodermic of of these conditions without first having morphia and atropia. Radiograph alone ascertained the source of the pus. A will not differentiate between kidney brief report of the following case refer- and intra-abdominal lesions, yet it may red to us by Dr. Brenizer will illustrate be the means of locating a renal or ure- the value of this precaution. teral calculus. In a certain percentage Mrs. A Age 19. of cases, gall stones may be detected in F. H. Ne<'-ative. this way but these must be differenti- P. H. No previous severe sickness. ated from nephritic stones as well as P. I. Severe pain in the right side intra and extra ureteral shadows, by 294 SOUTHERN MEDICINE AND SURGERY June, 1922 ureteral catheterization and uretero- made by a careful urological examina- pyelograms. tion. To illustrate again, a young man, The skill "of the urologists and radio- 38 years of age, reported at our Clinic logist is often taxed to differentiate be- sometime since with a large tender mass tween the shadows of a calcified gland in in the right hypochondriac region, which the course of the ureter and a ureteral extended to the crest of the illium, upon stone or to explain the pain in a slight- whom a tentative diagnosis of appen- ly movable or kinked ureter, but these dicitis had been made and an operation, may be definitely worked out by the with some reservation, advised. His exercise of study and patience. In for- temperature was 102, pulse 80, leucocyte mer days these gland shadows led to count 9000, R. B. C. 3,200,000, haemo- extensive, prolonged and dangerous g^obin 80 per cent, non-protem nitrogen operations for the removal of ureteral 65 mg. and preformed creatmm 1.15 stone, but today the aggressive surgeon ^S- per 100 cc of blood. His left kid- would not think of operating for such a "ey had been removed six months pre- condition without first having determin- viously on account of a very large stone ed by ureteral catheterization and radio- and infection. The ureteral catheter graphy whether the shadows were due was easily inserted and 52 ounces of pur- to stone or calcified glands. This can "lent urine .withdrawn. The tumor, of be determined very definitely course, disappeared and the diagnosis Caulk says that 27 per cent of the °^ hydropyonephr/osis established A cases of ureteral and kidney calculi, ana- f'^^^ "^''[^K^ ^^"^^ ^^J^ ^^^" "^^^^\" lyzed at their Clinic in 1916, had had an ^^'^ f ^^ ^ad an operation for appendi- appendectomy for abdominal pain with- ''^'^ ^een performed without first hav- out relief. He estimates that only 10 J"^ ^^^^ ^ ^^^^^"^ urological examma- per cent of such mistakes are made to- Jl' , day. This is considerably greater than , ^"^^ unnecessary surgery has been it should be done, ever since we have been able by T. , ' 1 . X 11 • , , . means of instruments of precision, to Renal aiid intra-abdominal lesions definitely diagnose the above named con- may coexist. In such cases one of them ^-^-^^^^ ^^^^ mistakes are becoming may be overlooked The presence of ^^^3 ^^^ j^^^ frequent. The exploratory gall stone and renal infection is a com- operation is practically a thing of the mon occurrence. Hematuria and pam ^^ ^^^ especially is this true of blad- in the right hypochondriac region, with ^^^ ^^^ Sidney surgery, an X-ray shadow on that side, does ^^^^^^^ symptoms are produced by not mean that the blood is coming from p^j^j, diseases, appendicitis, kidney the right kidney The shadow may be tuberculosis, or any kidney infection, m the gall b adder and the blood com- ^^^^^ j^ ^he ureter or bladder, seminal mg from the left kidney or bladder. We vegj^ulitis, prostatitis, hypertrophy of recently had a case of sever rena colic the prostate gland and certain lesions on the left side due to ureteral kmk and of the central nervous system. Fre- radiography showed the gall bladder q^ency of urination with hesitancy and filled with stones. diminished force, accompanied with a Abdominal tumors, by palpation alone, sensation of inability to completely are frequently very difficult to locate, empty the bladder, usually means hyper- They must be differentiated by the trophy of the prostate gland but ob- process of elimination. A large tender servation cystoscopy and bladder cathe- mass in the right hypochondriac region, terization are necessary to ascertain the associated with fever, muscular rigidity, form of hypertrophy, whether malig- nausea, high leucocyte count, and quick- nant or benign, as well as the amount ened pulse rate, may mean disease of of residual urine. Radiography and the appendix, the gall bladder, or a digital rectal examinations are import- hydropyonephrosis. Usually a definite ant, but largely in a confirmatory way. diagnosis of these conditions can be Another important field in urology is June, 1922 ORIGINAL COMMUNICATIONS 295 the location of hemorrhage in cases of val between them will be visible. It is hematuria. The source may be in the only when they are in actual contact urethra, bladder, ureter, or kidney. If that there will be no interval between the hemorrhage is profuse, observation them. systoscopy is sufficient but if it is only It is often very difficult to distinguish, microscopical, ureteral catheterization is especially in a thin individual, between necessary. To ascertain the cause of the a dense gall stone and a stone in the hemorrhage, uretero-pyelograms and pelvis of the right kidney. If one will functional activity tests are frequently introduce a catheter, a stone in the gall necessary. In settling claims against bladder will move much more on respir- corporations, this differentiation is very ation than the end of the catheter in the important. Injury to the kidney, as a pelvis of the kidney. If necessary an rule, is far more grave than that to the opaque solution may be passed into the bladder. A faker in a railroad accident kidney pelvis and the same procedure usually claims injury to the back or will determine whether we are dealing kidneys. ^^'^^^ ^ S^^^ stone or a urinary calculus. Discussion. Dr. A. J. Crowell Closes Discussion. ^.ir^ „.. ,,. I don't know that there is anything I Dr. A. L. Gray, Richmond, Va. ^^^ ^^^ ^^ ^^^^^ ^^^ ^^^^ ^^.^^ ^^^^p^. I wish to discuss briefly the differen- to indorse Dr. Gray's ideas about fluoro- tiation between urinary calculi and cal- scope. In differentating these shadows cified lymph nodes and other concretions i think his plan quite helpful. We very outside the urinary tract. frequently get the radiograms at dif- Dr. Crowell has shown us X-ray plates ferent angles, first from one and then made with the opaque catheter in the the other side. In that way if the ureter. If the catheter happens to shadow is in front or back of the ureter cross a calcified lymph node, which is you can locate it. The obstruction offer- immediately behind or in front, the plate ed by the presence of a stone in the will not give you the information you ureter assists very much in working out desire. If the ureter is entirely blocked these cases, by a calculus, the end of the catheter will be in close contact with the stone, but if the ureter is pounched or if the ^^^^^,, , , » ^, . T^T^nr.nrr> r^T^ calculus is too small to block it complete- OSTEOMALACIA - REPORT OF ly, the catheter will pass. We have now CASE. to determine whether the concretion is gy charies p. Mangum, m. d., Kinston, N. c. in front or behind the ureter or whether it is immediately in contact with the A fairly well developed child of five catheter. years, carried in her father's arms, was I find it most advantageous to resort brought in on April third with the fol- to uroroentgenoscopy rather than puro- lowing history: graphy, in other words, we resort to the The baby has never been able to fluoroscope to determine for us the exact stand or walk. She is the fifth child location of a stone. A calculus of aver- of normal and healthy parents. Labor age size, if it is distinguishable on a was normal, no instrumentation. She plate, should be visible in a medium siz- was breast-fed through infancy but ed individual under fluoroscope, provided was not weaned until about the eight- the eyes have been rendered sensitive eenth month. Teething began at the by rest in a dark room for at least fifteen fourteenth month. The mother does minutes before making the examination, not recall at what time closure of the If the stone and catheter are seen, the fontanelle occurred. The mother notic- patient may be rotated and if it is not ed that the left leg was held in an odd in actual contact with the catheter but position — slightly flexed and adducted — in front of or behind it, a distinct inter- when baby was about five months old SOUTHERN MEDICINE AND SURGERY June, 1922 and at about the sixth month she notic- ed quite a deformity — a bulging forward of the thigh near the hip joint. At the age of three years baby had a left otitis media with spontaneous rupture of the drum and discharge of pus. Baby was one year old before she attempted to creep and two years old before she tried unsuccessfully to stand or walk. The deformity constantly became more marked. There is no evidence of aenemia. Diagnosis — Osteomalacia with spon- taneous fracture of left femur. SOME FURTHER OBSERVATIONS AND REPORTS OF CASES IN THE INSTILLATION TREATMENT OF ENURESIS IN CHILDHOOD. William R. Barron, M. D., Columbia, S. C. Enuresis, nocturnal or diurnal, in chil- dren is not noticed until the child is about four years of age, and then they begin to pollute their beds at night or their clothing during the day with vary- ing regularity and frequency. Sometimes the causes of enuresis are easily discovered, but most often they are obscure. Briefly, the discoverable causes are enumerated by Keyes as fol- *Reacl before the Tri-State Medical Associa- tion of the Carolinas and Virginia, Norfolk, Va., February 22-23, 1922. lows, and the finding of the causes as enumerated below makes obvious their treatment by removal wherever possi- ble: 1. Congenital deformity, such as epis- padias, etc. 2. Tuberculosis or stone. 3. Phymosis, and in girls, adhesions of clitor's, pin worms, adenoids, tonsils, etc. 4. Congenital lack of development. 5. Enuresis is seldom associated with chorea and tabes. 6. Infection of the bladder. A. B. Schwartz, in the Boston Medi- cal and Surgical Journal for October 22nd, 1914, at page 631, in an article entitled "A Study of Two Hundred Cases of Enuresis," says: "One hundred and forty-eight cases were in the male, 98 in the female ; three were diurnal, 134 nocturnal, 89 both diurnal and nocturnal; 13 of 21 cases operated upon for tonsils and adenoids showed no improvement, six were not heard from, one reported 'better' and one spontaneously cured a year later ; 29 of the series showed abnormality of the genitalia, redundant prepuce 12, prenup- tial adhesions 5, phymos 5; 10 of these were circumcised, but only two of these were heard from ; one was improved and one not improved. "Digestive disturbances and anemia seemed to be no more frequent in this than in other groups of children. A nervous element, tic, chorea, retarded mentality, was found in the families of 56 of these cases. The results of the treatment were similar to those of other writers." Emerson, William R. P. : The Treat- ment of Enuresis without Drugs. (American Journal of Diseases of Chil- dren, May, 1918, p. 339.) "This writer states that enuresis in children is not a disease, but simply the persistence of an infantile condition or habit. Why this habit persists in one child and not in another cannot be ex- plained. "Numerous affections have been con- s'dered possible causes of this condition, but the author thinks the real cause has not been found. In his series of cases, the treatment of no one of these affec- June. 1922 ORIGINAL COMMUNICATIONS ^ 297 tions has relieved enuresis. larly treated. The method carried out "The treatment consists of four meth- by the writer is as follows: ods: In girls, I use a small glass female 1. Mental suggestion. This consists catheter with a rubber tube attached, of arousing the patient's interest and With the use of antiseptic precautions, attention to the act by rewards and other insert the catheter into the bladder, mental suggestions. This method re- Then instill through the catheter into lieves about 40 per cent of all cases. the bladder one ounce of three per cent 2. Establishing the dry habit. This argyrol solution, letting same remain in is accomplished by teaching the reflex the bladder from one-half to one hour, to act at regular intervals, and always when it is voided. This is done every before the time the "wet habit" occurs, day in some, in others every other day. 3. Local irritation. This is brought The strength of the argyrol is gradually about by irritating the vesicular sphinc- increased, until in some cases a ten per ter and the posterior urethra by means cent solution is borne without irritation, of a b3Ugie-a-boule, so that sensory im- It is not well to use strengths of argyrol pulses passing to the brain will become solution that irritate, because they will intensified sufficiently to attract the pa- not be retained and will also make the tient's attention, until the habit of con- child object to treatments. trol is attained. In most of the boy patients, instead of 4. Cerebrospinal irritation. This is inserting a catheter, I usually inject the produced by the injection into the spinal argyrol through the urethra with a bulb canal of physiologic sodium chlorid pro- syringe, washing out the urethra with ducing such stimulation as to arouse the plain sterile water, forcing the argyrol whole mechanism into consciousness, into the bladder. when habit holds it under control. Since my first paper on this subject These methods, singly or combined, two years ago, quite a few of my friends have been sufficient to relieve the 34 in the fraternity have used this method cases in his series." and have been kind enough to report to All of the cases referred to and treat- ^^ their almost invariably favorable re- ed by me had none of the above obvious suits. To date I have treated about 35 causes, and so I have been forced to cases, mostly of the nocturnal type and class them as (ideopathic) . crvptoge- in boys. So far as I have been able to netic, and it is in this class of cases follow these cases, at least 75 per cent that the following treatment is given, ^^ave remained cured, some of them hav- This treatment suggested itself to me in& received as few as three treatments, by my observations in endo and cysto- In review of the literature on this sub- scopic work in adults. Many of these ject, I have been impressed with the had had irritated, congested and hypere- paucity of the cures reported and know- mic areas around the vesicle neck and ing of the distress and annoyance given nearby regions as sequelae to previous both to the parents and the little pa- specific cause; stones, large prostates, tients, I felt that since the above method etc. This hyperemia in turn reflexly has given relief in the biggest percent- causes frequent and unpleasant uri- aoe of cases on which it has been tried, nation. This unpleasant condition that th's report is justified, was then easily relieved by top- Discussion ical application. Now, it had already been observed and was known that some- Dr. E. T. Dickinson, Wilson, N. C. times the mere passing of a catheter re- There is one important point, I think, lieved enuresis in children. Combining I would like to call attention to. It is this fact with the above deduction of the a treatment without medicine and with- similar condition in adults, it appeared out suggestion. I think it will cure 40 logical to the writer that this crypto- per cent of the cases if not 100 per cent, genetic enuresis in children was merely I have found 100 per cent so far. a reflex habit established by a hypere- As many beds as are being wet every mia as above outlined and could be simi- night in this country we could not ex- 298 SOUTHERN MEDICINE AND SURGERY June, 1922 pect to ever have much effect on it if the you urinate together. There is some children have to be carted to the office congenital deformity disturbing the every day and examined, treated, etc. nerve supply, and in this way we have So the easy way is the thing that gives the enuresis. effects, if we want effects instead of A further illustration proves this, patients. The reason most children wet that quite frequently we have nocturnal the bed is that the bladder is anesthetiz- enuresis and not daylight, because the ed. It is not sensitized enough and the will power comes in while awake and reason it is not is that the child is very greatly controls this devitalized or low tired. The child plays all day and goes nerve force, which in turn controls the to bed very tired. He goes to bed late, sphincter, but as soon as patient falls as a usual thing, they go to the movies asleep loses the will power, which is these days before they go to bed and followed by urination. The treatment there was something else back yonder that the doctor gives is one of stimula- the same as now. They are very tired tion. This is what is indicated. The and the bladder is anesthetized, conse- bladder is stimulated chemically with quently when the bladder is full there is medicine such as argyrol and thus the no report and the child wets the bed. sphincter is stimulated. If you put that child to bed at sunset The next case of enuresis I have I am —you have to be specific about that — going to give a little faradism of the you can't say it is a cloudy day and I sphincter muscle as a stimulus, as this don't know when the sun sets. Watch to my mind is the rational treatment the sun and whenever the sun goes based on definite congenital pathology, down, put that child to bed, and wake ^ ^ , „,.„. „t . • . ^ ^ it when the mother goes to bed and cause '^^^ ^om A. Wilhams, Washington, D. C. it to void, and it will go through the bal- Now is the winter of our discontent ance of the night without wetting the made glorious summer by this son of bed. It may wet the bed a few times, Columbia. The same might be said of but cure is apt to be permanent after the sons of Suffolk, Kinston and Wilson, a week or ten days with continuation of One swallow does not make a summer, this management. however, and there are most varied con- Dr. J. E. Rawls, Suffolk, Va. tributions to the solution of this diffi- I had a very interesting case about cult problem, two months ago. During the physical To state the physiological problem examination I found a deformity over will help to explain the success of pro- the sacrum. A deformity that I had cedures so unlike as installation, depres- seen in several cases before, but I did sants, excitants, decreasing fatigue and not know the significance of it. psychotherapy. The filling of the blad- About one week ago one of the doc- der produces increasing stimuli which tors associated with us called my at- influence the spinal center to relax the tention to an article beautifully written sphincter. However, the sphincter cen- and illustrated in the last Mayo Clinic ter can be in turn stimulated by cere- by Woltman, One of these plates in bral influence which is a psychological this illustration was a reproduction of matter. When the spinal cord is severed the case that I had seen two weeks be- above the influences cannot reach the fore. It was what this doctor called a center and incontinance occurs. The in- sacral dimple or fovea Sacralis. I said dividual above the grade of idiot can he is nearer the point than anybody yet. learn to exercise psychic control even He went on to state that spina bifida, when the different stimuli are very although at times very slight, is one of strong. Every mother knows how to the greatest factors or causes of enu- teach her child this until it becomes au- resis. To my mind that greatly explain- tomatic, so that a volition is required ed the whole phenomenon. As the coc- to void the bladder, and to retain the cygeal nerve supplies the sphincter mus- urine becomes automatic. Naturally cles of the rectum and of the bladder, this is more readily accomplished when they work in unison — you deficate and the attention is awake. During sleep June, 1922 ORIGINAL COMMUNICATIONS 299 attention is diminished and that is inflammation. It is a sedative effect, why there are individuals who although If you relieve inflammation you haven't they can control micturition while the irritation — you have the desire to awake cannot do so asleep. It is not be- hold. That is the only explanation I cause the afferent impulses are over have for results, strong but because the inhibition is in- sufficient. These are the cases curable by skillful psychotherapy, we have to re-educate the child. gQjyjE OBSERVATIONS ON ENDO- Again, when the neural tracts are m- ^^^p^ rfport of FftlTR niF adequate, as in spin-bifida the inhibi- SCOPY. REPORT OF FOUR DIF- tory control must receive a more inten- FERENT CASES. sive education, and in these cases too ^ ^^ p^^j^^. ^ ^ ^ ^ Phillips, m. d. psychotherapy may succeed. To prevent Charlotte, N. c. the child getting tired in these cases is simply to prevent the failure of cere- j^ie field of Endoscopy has become bral control which extreme fatigue p,^g ^^ g^g^t importance. The problems brings. Again, in cases where the stim- ^^lat develop in this branch of the spe- uli are over-intense as in diabetes, train- ^,{^1;^^ ^^^^k are becoming more and more ing can teach the individual to wake up difficult. The cases are increasing in when the degree of extension is reached numbers very rapidly. These facts give where voiding is imperative. The secret my apology for presenting this paper, is in the way the child is influenced to ex- -p^j^ years ago there were very few cases ert an intense concentration upon the q,. they were not recognized, but today act of holding the sphincters until an ap- they are reported by the hundreds, propriate moment. It is only when the Before taking up Endoscopic work I child himself actively collaborates in this thought the most difficult part of it that exhortations become efficient. A ^^.^^ the introduction of instruments. It motive must be furnished in lieu of ^vas considered a difficult task and, hav- scolding or punishment, or better the jng accomplished this, the removal of desire to please those who manage him, the foreign body was then an easy thing or, best of all, the wish to do what is to do. The operator only had to pass a right. Enuresis in children is often a suitable forceps and deliver the intruder, sign of slovenly management by the pa- The above conception was erroneous, rent. Few realize the degree of control Now. with the proper instruments to suit of which a very small child is capable. I the individual case, the introduction is received a demonstration in the two- usually an easy task but the problem of year-old grand-daughter of a Norfolk the removal of the foreign body is very physician with whom I dined last night, great and one which must be studied A true psychology observingly applied and a plan of procedure outlined before by the parents had produced a most im- an attempt is made to remove it, i. e. pressive behavior on the little girl. the surgeon must have a mental picture Dr. William R. Barron Closes Discussion, of the location, position and relation to I don't agree with Dr. McNairy or surrounding tissues before he can suc- Dr. Rawls that we need stimulation or cessfully remove the foreign body with- an anesthetizing, as you say. If you o"t injury to the host. Just as the ob- have an ulcer in vour mouth and get stetrician studies the position of the some acid in there vou are going to spit foetus in relation to the maternal parts, it out in a hurrv. Something telegraphs so must the Endoscopist study the posi- to your brain, "I am irritated, and get ^ion of the foreign body and the relation out of the way !" You get the message of its every part to the bronchus or oeso- now that says to the brain, "I want to P^agus. To do this the x-ray is indis- , ,„ , . ,.,,,, ... pensible. empty! and in a child s brain it emp- ^^^^ the roentgenogram, the diagno- ties. The only explanation I have for ^js of the opague foreign bodies is not the success of this treatment is relief of diflficult, as we always get a clear shad- 300 SOUTHERN MEDICINE AND SURGERY ow of these and it is only left for us From the physical examination to determine the nature of the object (which I always leave to a competent and whether it is in the air passages or specialist) we get the condition of the the oesophagus. lung as to its function giving careful Of the non-opaque foreign body the consideration to percussion and auscul- diagnosis is more difficult, but by giv- tation of the entire surface of both lungs, ing special attention to accuracy in Case No 1. Plate No. 1^ technique a Positive conclusion can be June 15, 1921. Dr. Ashe's case, arrived at. The signs of this condition Baby G. Age 14 months, as seen in the x-ray examination are few Open safety pin in oesophagus just but when considered together are quite above diaphragm, point upward, conclusive of obseruction, which is al- Removed. Cured, most always due to the inhalation of At first attempt I endeavored to re- some foreign substance, but not in every move pin by point protection method of instance ; as in one case we will report C. Jackson but failed to do this because later. The signs as seen in the radiogram it was against diaphragm closure of rre: emphysema of the obstructed lung, oesophagus. At second attempt I forced with widening intercostal spaces, de- Pi" into the stomach and then turned it pressed diaphragm on the affected side and removed it within the oesophago- and the mediastinal structures displaced scope. on the opposite side. On flouroscopic ex- amination we observe the diphragm of Case No. 2. Plates Nos. 2, 3 and 4. the affected side is limited in movement January 14, 1922. Dr. Houck's case, or sometimes immovable, while that of M. C. Age 16 months, the opposite side presents exaggerated Five days before I saw child it was movements. In the cases of longer eating a piece of cocoanut and trying to standing, we find considerable thicken- get another piece from little brother, ing in the tissues of the obstructed lung, It choked on that in its mouth. Mother which usually goes on to abscess forma- says it had a fit of coughing and was tion if the obstruction is not relieved, blue for something like a minute. It On account of overwork of the unob- continued to have some coughing and structed lung there is found increase in ^^^ ^'^^ ^^''^^' Wednesday. Thursday density of the bronchial markings. Plate I — Case No. 1 — Baby G. Age 14 months. Diagnosis, tjafety pin in oesophagus. Result, Removed. Cure. Plate 2 — CabC No. 2- M. C. A^f 16 months. Diagnosis, Pieces coacouut lij^hl bronchi. Emphysema upper lobe right lung. June, 1922 ORIGINAL COMMUNICATIONS 301 was better; fever again Friday. I saw the child Saturday. Examination — Temperature 101 de- grees F. Occasional wheezy cough. Much mucus, W. C. 18,100. Rales over the lower part of right lung ; upper lobe somewhat emphysematous; a few rales Plate ;i— Case No. 2— M. C. Age 16 months. Diagnosis, Pieces coaronut right bronchi. .After removii g i>iis t)y hroiichoscoiiy . over lower part of left lung. X-ray re- vealed some emphyema in upper lobe right lung. Some clouding and thicken- ing of middle and lower lobes. Diagnosis — Foreign body, right bron- chus, probably largest piece in upper stem bronchus. A bronchoscopy was done; no f. b. found ; much pus removed. A septic temperature w-as present for next ten days. A second bronchoscopy was done ; no f. b. ; great deal of pus removed. From this time, child began to improve. Four days later returned home. The last letter I had from Dr. Houck said the child had recovered entirely. Remarks: This case, I think, had a number of small pieces of cocoanut in- haled, therefore unable to find them. During the second operation a small .sponge was accidentally turned loose in the trachea. This was quickly removed from left bronchus. An accident that should not happen. Plate 4— Case No.2— M. C. -Age 16 nionllis. Diagnosis, Pieces coaconut right bronchi. One week \a\ti showing abscess formation lower lobe rit'lit lung ai.d removed by bronchoscopy. Resnlt, Cure. Plate 5— Case No. 3— C. L. Age 14 months. Diagnosis, Peanut in right bronchus, tmphvsema right Inug. Result, Removed. Cure. Case No. 3. Plates Nos. 5 and 6. May 9, 1921. Dr. Brawley. C. L. Age 14 months. Saw child May 9th, 1921. Twenty- four hours before child was eating some peanuts and while laughing inhaled one. 302 SOUTHERN MEDICINE AND SURGERY June, 1922 A fit of coughing was immediately set up. When I saw this case it had a tem- perature of 103.8 degrees F., a wheez- ing cough, W. C. 14,600. By careful physical examination and study of radio- gram we made diagnosis F. B. Right Bronchus. A bronchoscopy was done, removing a large half peanut from right lower stem bronchus. This child was cured. Next day had to do a tracheotomy on account of subglottic edema. Plate No. 7. The x-ray picture was typical of a foreign body obstructing the left bronchus. The lung was great- ly emphysematous. The excursion of diaphragm was greatly limited on left side, etc. Plate 6 — Case No. 3— C L. Age 14 months. One half hour after removal. K. lung cleared up. Case No. 4. Plates Nos. 7 and 8. January 11, 1922. Dr. Yates Faison. C. H., Wt. 7 1-2 lbs at birth. At two weeks of age mother noticed the child had some difficulty in breath- ing. One week later same difficulty, perhaps slightly worse, when she called Dr. Faison. Child well nourished, nor- mal gain in weight; other examinations negative, excepting at each inspiration there was excessive movement of diaph- ragm ; so much that the anterior abdom- inal wall was drawn inward and upward. During the next two weeks the child lost weight. At five weeks of age a radiogram of chest was made. The Wasserman was negative. Leu- cocyte normal. Plate 7— Case No. 4— C H. Age 5 weeks. Inagnosis, Congenital stenosis left bronchus. Result. Death. Showing emphysema left lung, all meriia stinal .structures including the heart pushed far over right side of chest. Probable Diagnosis — Foreign body. Left Bronchus. A picture was sent to Dr. Manges, of Philadelphia, and his opinion was there must be a foreign body in the left bron- chus. A Laryngoscopy was done (unable to pass smallest bronchoscope without trauma to larynx). There was no in- flammation in the larynx nor trechea, no pus nor mucus present. The child did not have a cough, the temperature was normal. The child had difficult breath- ing, would become blue when crying. The question, what was the trouble with this baby. At eight weeks the child died. P. M. revealed a congenital stenosis of left bronchus. June, 1922 ORIGINAL COMMUNICATIONS 303 Plate 8— Ca'e4— A Nor. nal trachea ami bronchi cf child. B.— •'. H. Shiwitifi left bronchus larger than riiiht. Two stenosed bronchi to upper lobe left lung. Plate No. 8. This stenosi.s admitted a few bubbles of air at inspiration but closed at expiration. The child died from gradual asphyxiation. In a review of literature for the past eight years did not find a similar case reported. Dr. Levy reports 22 cases congenital absence of one lung, 15 of these were left side. STALKING THE STREI>TOCOCCUS* By Edgar M. Long. Hamilton, N. C. A streptococcus, under the micro- scope, does not inspire respect by its appearance. It looks insignificant. It resembles nothing quite so much as a point in space — a thing which, in its very definition, is without dimension and therefore insignificant to the point of being non-existent. But Euclid had proper respect for the point in space ; he moved it in a constant direction and generated a line ; the line, moved side- wise, described a plane; and the plane, in like manner, gave birth to the cube, whose volume may be sufficiently comprehensive to include the universe. — i •Read before the Tri-County Medical So- ciety of Beaufort, Pitt and Martin at the regu- lar quarterly meeting held in Greenville, N. C, Feb. 9, 1922. A single streptococcus, individually isolated and segregated, is like the point in space not merely with respect to size and personal appearance, but also because its possibilities are almost infinite. Its latent capabilities, expend- ed in a diflferent direction, might have made the history of human achieve- ment read diflferently; unleashed with- out check upon humanity, all history might well have come to an end with the exodus from the Garden of Eden. The streptococcus is a born villain. He does all the harm he dares. He is es- sentially hostile. Unlike the colon ba- cillus, for instance, he is entirely in- capable of living on terms of peace and good-fellowship with his human host. He is invariably an enemy. Moreover, he is an enemy that does not command the respect of his adver- saries. The pneumococcus invades the lung and produces a most serious, vio- lent and devastating illness; but every- thing is in the open. Immediately upon its occupation of territory, we are able to determine with a fair degree of ac- curacy the location, degree and extent of the involvement. We know from va- rious symptoms about how heavily the invaded organism is being bombarded with toxins. We know, by counting the days from the sharply-defined on- set, about when the crisis may be ex- pected. The pneumococcus seldom strikes below the belt. But, in Afro-American parlance, striking below the belt is what the streptococcus don't do nothing else but. To change the metaphor slightly, gas- attack and submarining of hospital ships are his favorite methods of mak- ing war. His favorite practice is to wait until some other infection has in- vaded the human and been fought to a standstill ; then, just as the armistice is about to be signed, he wades in and mops up, almost before his presence is recognized. He rarely launches an at- tack without waiting for the ground to be prepared by some more courageous ally. Probably because of these character- istics, the human organism seems to fear him more than any other enemy of 304 SOUTHERN MEDICINE AND SURGERY June, 1922 the bacteriologic world. With probably which all influenza patients crave. His no other bacterium is the negative op- bronchitis, quite loose and with free sonic phase so marked and so quickly expectoration on the occasion of our last obtained. The watery, clear pus from call, has tightened up, and there are a streptococcic infection is itself evi- areas of very harsh vesicular breathing dence of the reluctance with which the over the lungs, chiefly in the bases be- phagocytie counter-attack is made. The hind. The temperature, not above 102 tendency to slow recovery and recru- thus far and, possibly, normal for a descence in conditions like erysipelas day or two, has risen to 103.5 or 104. shows how poorly, by comparison, the The skin is dry and harsh. The tongue human system protects itself with anti- getting foul, often with a blackish cast, bodies under the stimulus of invasion. The pulse rapid and irregular in vol- The jagged saw-teeth of the tempera- ume. (I think this last symptom is ture-curve spell in letters plainer than especially worthy of note, being un- print a message of the fitful, disorgan- usual.) The patient knows he is much ized, and usually inefi'ectual, character worse, but cannot say exactly how he of the defensive reaction. Sad indeed knows. A patient in the condition I is the fate of his victim, when the have tried to describe, given nothing streptococcus is feeling good, and when more than the usual symptomatic treat- such victim is obliged to fight it out ment, may come through with his life; with no weapons but those God has so may a criminal condemned to the given him. chair; he may get a pardon. As I have already remarked, it is We all know only too well what fol- comparatively seldom that the strepto- lows in the natural course of events: coccus makes a primary attack. He the uncontrollable fever of "septic" likes better to appropriate the ail-but- character, sometimes with chills and conquered victim of some other infec- sweats; the prostration; the merciless tion; there are certain diseases that he cough and restlessness; the dreadful particularly favors as fore-runners — apprehension ; the chest that presents measles, scarlatina and, most of all, in- a hopeless jumble of sounds to the fluenza; there are, of course, also the stethoscope, that seems to be full of other pyogenic cocci. fluid when there is none, that appears Those of us who worked through the to contain no fluid when it is full of it. influenza epidemic of a few years ago We have all watched these unfortunate will recall with a shudder that condition ones go from bad to worse, and from popularly known as "flu-pneumonia," worse to ultimate worst, the while our and which yet was not pneumonia — cer- power to help is limited to reassurances tainly not pneumonia in any of its reg- that do not reassure and whose empti- ularly recognized forms. We know the ness is as apparent to our patient as influenza patient would progress it is to ourselves. This condition, which through his attack just as any other we have come to call "flu-pneumonia" influenza patient, often even reaching a for want of a better name, has been stage that we would regard as begin- somewhere termed, most aptly I think, ning convalescence. We have seen them "cellulitis of the lungs." Certain it is doing so well that we scarcely thought that the streptococcus is the chief eti- it worth-while to see them any more, ologic factor. Then we would be called back, to find But the versatile streptococcus does them worse, the trouble often so inde- not confine his activities to the lungs terminate in nature that we were apt of the flu patient. Consider, if you to give it scant attention until constant please, the pregnant woman who falls repetition tano-ht us better. a victim to influenza. Her situation is Such a natient usually tells us he has hazardous in the extreme. I have' talk- had a chill after feeling a draft from ed with a number of physicians from as an open door, most frequently after many sections of the eastern states who drinking a glass of some cold liquid stated, as serious fact, that absolutely June, 1922 ORIGINAL COMMUNICATIONS 305 one hundred per cent of their pregnant cause. So often, indeed, do we find this women contracting influenza miscarried, sequence appearing over our own sig- and that an almost as large a percent- natures that we are prone to regard age died. Fortunately, most of us en- broncho-pneumonia as an inevitable joyed somewhat better luck than this complication in a certain percentage of with our pregnant flu cases, but I ven- measles cases. In my opinion, as I shall ture to say that none of us undertook set forth later on— and which I offer such a case without a twinge of appre- for what you may think it to be worth '^^"s^o"- —a great many of these secondary It was my belief, during the first broncho-pneumonias can be avoided, months of the epidemic, that the mis- being streptococcic. Of this, more carriage was the result of the uncom- anon. plicated influenza infection, and that I feel that I should apologize for the subsequent death was the outcome mentioning scarlet fever at all, for in of streptococcic wound infection of the my entire practice I have seen not more denuded uterus; but further observa- than a half-dozen cases, and all of these tion convinced me that such is not the except one have been very mild and case precisely. Perhaps I am not qual- entirely uncomplicated. I drag it in by ified to express an opinion here, for I the heels merely that I may include had the good fortune to have very few among my cases the one that was not such cases. Those that came to my mild and uncomplicated, whose course knowledge, however, all adhered to one had much in common with influenza, unvarying course. and whose complications I believe to The onset and the course, up to a have been streptococcic inasmuch as certain point, are practically the same they responded to antistreptococcic as usual. Then comes the chill— possi- treatment with a promptness and com- bly "chilling" is a better word, for of- pleteness beautiful to behold. This case ten the sensation of cold is quite fleet- seems so interesting, and the sugges- ing, and practically always it is ascrib- tions to be gained from its study so ed to contact with something cold; fol- significant, that I cannot bring myself lowing this, 'the high, erratic tempera- to leave it out. ture, the rapid pulse of irregular vol- When the parturient woman — for ume, the usual pulmonary jumble — in purposes of economy or because "a a word, the signs and symptoms asso- granny was always good enough" for ciated with onset of streptococcic in- her husband's mother— undertakes to fection. Then, after all this, comes the bring her baby into the world with the miscarriage, the puerperal sepsis and aid of the larded ethiopian finger and death. As I said before, I am but stat- suflfers a chill and cessation of lochial ing my own observations of a few cases, discharge some days later, we are wont and am not prepared to back up the to begin at once to pave the way for a view with any statistics or quotations graceful retirement in favor of the un- If any are present whose observations dertaker. We intone the word "strep- differ from mine, I shall be pleased to tococcus" with reverent awe, and feel have them tell me so. that we have made perfectly clear the Any layman past the age of puberty reason why any efforts of ours are un- will tell you that "it is dangerous to availing. In this instance our insignifi- catch cold on the measles." Laugh at cant-appearing friend, instead of follow- such traditional sayings as we will, ing up another bacterial invader, has they usually have some foundation in allowed the puerperal state to act as fact. The fact in question here is preliminary bombardment, himself fol- borne out by the number of death cer- lowing, in his usual manner, in the role tificates finding their way each year of shock-troops. We like to tell our- to the State Registrar bearing measles selves that these cases do not belong as the primary cause of death and on our files to mar the record of "no broncho-pneumonia as the secondary mothers lost." And we are right ; these 306 SOUTHERN MEDICINE AND SURGERY June, 1922 women die through no fault of ours. and strain our eyes, a cloud begins to There seem to be at least two excep- form in the direction of the entrenched tions to the general rule that the strep- enemy. Borne on the breeze, it increases tococcus does not launch an attack pri- in scope and floats steadily nearer. At marily and unaided. I refer to erysipe- length it is upon us. Men in the front las and cellulitis. It often happens, in ranks begin to gasp and fall to the these devastating and dangerous affec- earth in the throes of a horrible death, tions, that the streptococcus is the only More and more succumb, while we watch organism to be found. But, knowing and try to think, and the realization the character of the gentleman as we comes that our forces are being wiped do from other exploits, it does not seem out while our futile cannon have no unreasonable at least to suspect that he target and our foolish bayonets clatter follows his usual tactics here as else- to the ground in the absence of a breast where at the beginning of the invasion, wherein to bury them. Certain it is that some cases of ery- The call goes back through our S. 0. sipelas show the staphylococcus present S. for gas-masks, a frantic appeal, also. There are none. There is no time to Naturally, I have left out many of the make any. Obviously, there are but two manifestations of the streptococcus' ac- courses open to our commanding offi- tivity, such as follicular tonsilitis, acute cer: to remain and see his men die en articular rheumatism, otitis media, etc. ; masse ; or to beat a hasty retreat. He, but I think enough have been mention- being wise, orders the latter, ed in detail to make clear the point I In the lull after the retreat the en- wish to make. tire nation makes gas-masks with des- One of the chief reasons, I think, why perate haste. But there is little time, the human organism is so helpless to for the enemy advanced as we retreat- protect itself against the ravages of ed and are preparing another attack; the streptococcus is that the strepto- moreover, owing to the spent condition coccic invasion so often takes it un- of our resources, the materials are lack- awares. Suppose, for a parallel, that our ing. Clearly, the situation can have country is engaged in war. The war- but one outcome, unless Divine Provi- fare, we will say, is being conducted dence — or fortuitous circumstance, as along lines and with weapons that were you will — places the gas-masks in our considered orthodox and proper prior possession. to the world war. We fight it out with Such a situation is a close parallel to cannon, rifle and bayonet until we have the state of affairs in the human econ- the enemy retreating and ready to talk omy at the time of secondary strepto- terms of peace. Incidentally, we are coccic invasion. The new enemy, en- worn out and ready to talk peace our- tirely diflferent as to temperament and selves, though keeping it dark and put- weapons from all that the defensive ting up a bold front. body functions have been accustomed But suddenly we learn that the war to, finds the system barely able to cope is not yet over. Our scouts bring the with the force it has just routed, and intelligence that there is approaching utterly unfit to hold its own against a an army different from anything we fresh army even though such army ad- have had to deal with before. They hered to sportsmanlike tactics. The act queerly. Instead of the usual bar- phagocytes, in the absence of any ef- rage, we see the new enemy come to a fective opsonic backing, have no choice halt and dig in beyond the range of our but to keep their distance. The call artillery. They make mysterious prep- goes back for receptors specific for the arations, for what we know not. Nev- strepto-toxin and for amboceptor ex- ertheless, we unlimber our artillery and pressly made for the streptococcus. The fix our bayonets to be in readiness for depleted system lacks the materials, the the charge we feel is bound to come. time and the energy to furnish these But it does not come. As we wait necessities in sufficient quantity. The June, 1922 ORIGINAL COMMUNICATIONS 307 invasion spreads and increases in viru- ing it unnecessarily than the one of lence, and, in due time — usually a very giving it two hours late. Barring ana- short time — is crowned with easily-won phylaxis, its superfluous presence in the though undeserved victory. circulation is no encumbrance; its ab- To go back to our parallel. At that sence therefrom at the time of need crucial moment when the call goes back may well be fatal. for gas-masks, suppose that Divine To deliver to the patient in immi- Providence should in some way place nent danger of secondary streptococcic these indispensable things at our dis- infection the all-important help where posal. Suppose that the same stroke and when it is needed, three factors of good fortune gave us also a virulent must be considered: the time to admin- disease-germ that we might scatter ister; the amount to administer; the from an aeroplane through the enemy's way to administer, lines and thereby disorganize his resist- The Time — The proper time to give ance. Our army, saved from annihila- serum is the earliest possible moment tion and able to stand its ground, after first suspecting that streptococcus would merely wait for the ravages of is present. In such diseases as measles, disease to prepare the way, and then .scarlatina and influenza — particularly advance to easy conquest. influenza — I keep a close watch on tem- But (and please consider this "but" perature and chest. I instruct the nurse written in capitals and heavily under- to call me if the temperature remains scored), if the divine intervention is to above 102 for more than two hours, do any good, it must come in time; it Answering such a call, if the stetho- must come before the enemy has se- scope finds undue harshness of vesicu- cured a foothold and the added advan- lar breathing at any point in the vesi- tage of a decisive victory. Gas-masks cular areas, I judge that the time has are of small value to the soldier already arrived. If there are crepitant rales, gased to death, and weapons are wield- the time has not merely arrived, but ed most efi'ectively by men in bodily is probably past for the serum's magi- health. Moreover, the army functions cal curative effect. If there are areas better with morale and co-ordination of increased fremitus, bronchial breath- unimpaired by a panicky retreat. Di- ing, impaired resonance or hyper-reso- vine Providence, being omni.scient, will nance, I give serum anyway as a for- know exactly when to step in with the lorn hope. I regret that the lack of required assistance. case-records makes it impossible to give In the warfare of human and strep- any figures; but if my memory serves tococcus, however, the role of Provi- me, I have never, answering such a call, dence is taken by one who is himself found the process too far advanced for human and whose knowledge is there- serum to give its best effect except fore finite. Bulletins from the front of when adverse conditions made it im- his patient's battle-line reach him only possible to answer the call promptly, through his senses and. at that, through The Amount— I never give an adult the medium of the easily misunderstood less than fifty mils unless I suspect him wigwag signals called symptoms; and of being sensitive. After the initial only insofar as his knowledge and ex- dose I wait twenty-four hours before perience enable him to interpret these giving a second. At the end of this signals, and only insofar as the signals period the patient will be either very run true to precedent, is he in position much better or very much worse. If to know when to take from the ice-box better, it means that the serum came the package of biologic gas-masks and in time, in which case it is highly im- disease-germs — labeled antistreptococcic probable that a second dose will be re- serum— that he has been holding quired. If worse, it signifies that the against just such an emergency. Every- dose came too late to keep the infection thing depends upon his doing this in from gaining a foothold; in this event, time. Better far the mistake of giv- it is my practice to give fifty mils every 808 SOUTHERN MEDICINE AND SURGERY June, 1922 twelve hours, for the neutralizing ef- enough to be entered in the usual man- feet upon the toxin and the nourishing ner, I beheve dissecting out a vein un- effect upon the patient; it is conducive der local anesthesia is entirely justiried to comfort and rest if nothing more. It if the symptoms point to urgent need sometimes happens that one of the lat- of the serum. ter cases pulls through, but I regard Every pregnant woman gets a pro- such a recovery merely as additional phylactic dose of serum as soon as the proof that anything is likely to happen diagnosis of influenza or measles is in this world rather than as a triumph made; this practice has netted me a for serum, although I think the serum mortality expressed, so far, by the fig- assists materially in the recovery, ex- ure naught. erting only its protective effect as when In the matter of prophylaxis there is used in erysipelas, cellulitis or puerperal one other factor which seems to me to infection. be of prime importance — the avoidance The Way — In emergencies such as of chilling. The majority of my cases this we cannot get the effect of our have voluntarily ascribed the initial medication too quickly. That sera do chill to some definite cause; and where not fully absorb from the subcutaneous it is not done voluntarily, questioning tissues in less than twelve hours has will usually elicit the information that been pretty well demonstrated ; that ab- there has been some contact with ex- sorption is slow is evident from the ap- ternal cold. I have been forcibly struck pearance of the site of injection. Into by the frequency with which the initial a vein, then, our dose must go, if it is chill, or chilling, has followed within to be of benefit. In children with veins thirty minutes the swallowing of a too small for ready intravenous injec- glass of cold water or ice lemonade, tion, I often avoid the necessity of dis- So much has this impressed me that, secting out a vein for the purpose by in treating measles and influenza, I giving fifteen to twenty mils under the have long since reverted to the old- skin, as a prophylactic measure, before fashioned method of handling measles, there is any sign of impending strep- i. e., allowing no fluid that has not been tococcic invasion. Indeed, it has often at least slightly warmed and avoiding, seemed good practice, in infant and as far as possible, contact with any- adult alike, to give a prophylactic dose thing cold. I have been laughed at no in all cases of measles, scarlatina or little because of this, but the falling off other disease known to be a frequent in secondary pneumonias on my death forerunner of streptococcic infection. certificates has more than repaid me for To my mind, the one contra-indica- the embarrassment. One case, I recall tion for the intravenous method is the in particular, in beginning convales- belief that the patient is sensitive ; ana- cence from influenza, was fatally strick- phylactic symptoms are less apt to in- en with such promptitude after taking elude shock if the serum is given sub- a glass of iced lemonade that the nurse cutaneously. If the need is urgent, how- who gave it, being newly arrived and ever, I give anaphylaxis no more than without orders, and having been pre- a passing thought unless my suspicion viously trained to use iced drinks as a amounts almost to certainty. In my routine measure, was severely criticis- entire practice I have seen only two ed by the family, despite my efforts to cases, and only one that suffered any keep the cause of the disaster from shock. This patient, by the way, al- them. The same case is of further in- though he survived the shock only by terest in that over six hours elapsed the skin of his teeth, gave every indi- after the temperature rose above 102 cation that his beginning infection had before serum was given, been nipped in the bud, and made a In conclusion, I would like to report good recovery; I have no doubt that two cases, selected to illustrate two the serum saved his life. In small chil- widely different situations wherein anti- dren or others showing no vein large streptococcic serum demonstrates its June, 1922 ORIGINAL COMMUNICATIONS 809 worth. The first typifies that class of under oiled-silk and eliminatiton with cases in which, through an unusual de- calomel were the only therapeutic meas- gree of vital resistance, on account of ures employed. a feeble streptococcus, or because the By the 10th, when serum arrived, the site of infection is one of the less sue- situation was desperate. The entire culent tissues, the fatal issue is not yet face, scalp and neck, on both sides, imminent although the invasion is well were enormously swollen down to the established. In this class are erysipe- level of the supra-sternal notch with las, cellulitis and many cases of puer- the exception of a small area on top of peral sepsis. the head surrounding the parietal fora- T. F. P., 57, male. Came in about mina; this had been protected only by noon on March 7th. Was doubled up the constant application of gauze soak- as if in great pain and gasping for ed in iodin, which practically removed breath now and then. Skin pallid and the skin and caused great suffering, grayish ; lips somewhat cyanotic. Com- On March 10th fifty mils of Mulford's plained of periodic gripping pain in the antistreptococcic serum polyvalent was region of the heart, the spasms of pain given intravenously. The patient's bearing a close resemblance to the pa- groans, which, asleep and awake, had roxysms of angina pectoris. Pulse was continued incessantly for three days, rapid, regular in rythm but markedly stopped before the needle was with- irregular in volume. Complained also drawn from the vein. In fifteen min- of slight soreness behind right temple utes the patient was sound asleep, the and following the course of the carotid first sleep not induced by a narcotic vessels down into the neck. that he had had. The skin became The diagnosis was left in the air and moist without being clammy, also for an effort made to relieve the distress the first time. The natural sleep and with symptomatic treatment, which in- sweat continued uninterrupted from eluded stimulants and a quarter-grain 7:.'50 p. m. until 9 next morning, when of morphine. The patient was sent the temperature was found to be normal home and put to bed, where he at once and the only discomfort from the iodin dropped off into fitful sleep. In about burn on the scalp. The swelling of the an hour he awoke with a violent chill, face and neck was markedly less. The The chill lasted forty-five minutes and pulse was 90 and regular in every way. was followed by a rise in temperature to The next day, the 11th, the temper- 104.6. The angina-like paroxysms had ature rose in the evening to 100.6 and passed, but the soreness behind the the local condition was not quite so temple was much worse ; slight swelling good ; so fifty mils more of serum was and redness began to be visible here, given in the other arm. The result was The pulse was now running 125 and was the same as before. From then until very irregular in volume. the 16th there was steady improvement At 8 P. M. there began a profuse in both the local and the general con- sweat lasting until 10 :30, when there dition until, on the morning of the 16th was a second chill lasting fifteen min- there was scarcely a sign on the head utes. Meanwhile, the temperature never or face, and the patient was promised fell below 102.2, and immediately after that he might sit up some the next day. the chill it went back to 104. The pa- But friend streptococcus thought other- tient spent a wretched night in spite of wise. another quarter of morphine. I was sent for that night about one, Next morning, the 8th, almost the and found things much as they had entire right side of the face, scalp and been on the day of onset, except that neck was involved in an unmistakable the local process had chosen the left and violent cellulitis, and the septic side this time, and there was no angina- symptoms and prostration were ex- like pain. Greatly in fear of anaphy- treme. No serum being immediately lactic symptoms, I nevertheless gave available, local treatment with ichthyol another 50-mil dose of serum, intraven- 310 SOUTHERN MEDICINE AND SURGERY June, 1922 ously as before. The systemic effect was as good as it had been previously, but the local condition, next day, was not only no better, but had covered every square-inch of area above the level of the thyroid cartilage except the iodin-protected parietal region. This time, however, the general con- dition remained good, so no more serum was given and local treatment with ichthyol was again started. On the 18th, partly because I seemed to detect a slight difference in the feel of the scalp here but mainly through intui- tion, I made an inch-long incision through the scalp down to periosteum on a level with the ears about two inches from the posterior mid-line, and packed it with gauze. The next morn- ing I had the satisfaction of removing a pus-soaked dressing. The stained smear of the pus showed nothing but strep- tococcus forms. From then until the 25th, the syste- mic condition remaining good the while, the inflammation would not be entirely subsided in one place before it would break out in another ; a new focus would start almost every day. The incision closed on the fourth day after it was made, and there was no further pus or indication of pus. In a final effort to put an end to this game of hide-and- seek I started, on the 25th, a series of ascending doses of Mulford's strepto- serobacterin, giving an injection every evening and doubling the dose each time. After five days of this treatment every sign of the trouble, local and gen- eral, had disappeared, and the patient was able to resume business in about a week. As can be readily imagined, an infec- tion of this type and of equal virulence occurring in the succulent tissue of a vital organ, such as the lung, would without doubt have terminated fatally. I have not the slightest doubt that a dose of serum on the day of onset would have suppressed the attack. This case, as I have remarked, is given to illustrate the protective, the less bril- liant, effect of the serum. The second case that I have to report is illustrative of the action of the serum at its best — its curative effect: E. E., a boy of nine and delicate from infancy, was found on December 5th to have an eruptive fever that turned out to be scarlatina. The disease ran a text- book course, with the usual pharyngitis, bronchitis, etc. Improvement began about the 9th and slowly continued un- til the 15th, when things seemed to come to a standstill, leaving a low- grade bronchitis and tonsilitis and a constant temperature of 99 to 99.6. Things went on in this fashion until the night of the 20th. Then, answering a hurry call, I found the boy in evident distress: temperature 104.2; tonsils swollen until the throat was entirely filled up; throbbing ache and deafness in the left ear. The pulse was 120 and, I noticed, irregular in volume. The stethoscope brought to my ears an old familiar message, and I finished the ex- amination of the chest with the vivid illusion that the calendar had been turned back three years to place me at the bedside of a flu patient. It so hap- pened that I had in my kit a package of serum left over from treating — success- fully, by the way — a case of puerperal infection. Acting on this double hunch, I gave the serum at once, being fortu- nate in the matter of the vein. When I left the house an hour later, the temperature had dropped to 102.2 and the boy was enjoying a natural sleep. Next morning, the temperature was normal; pulse 90 and regular in every way; tongue and tonsils almost entirely free of inflammation; ear-ache gone and hearing perfect; hungry and begging to sit up. Best of all, the chest was clear as a bell, with no sign of trouble of any kind except the few coarse bronchial rales that had not been absent since the onset of scarlet fever. The boy was discharged on the 24th, in a very weakened condition, it is true, but one that promptly improved under tonic treatment. The child's prostration and the critical nature of the situation at the time the serum was given were so manifest, and the improvement dur- ing the night so magical, that the case attracted quite a bit of attention in the community. June, 1922 ORIGINAL COMMUNICATIONS 311 It is in this class of cases that serum sirable clinical schools the two years shines. To bring out the full brilliancy schools must expand into full four-year, of its response it must be given early— diploma-granting schools or cease to ex- long before there has been time to dem- ist. The logical result of the standardi- onstrate the streptococcus bacteriologi- zation of medical schools and the intro- cally. To use serum successfully in ob- duction of the laboratory method into taining such a result there are three the teaching of the clinical subjects has adverbs that must be kept in mind: been a decrease in the number of "Promptly," "copiously" and "intrave- schools, a limitation of enrollment of nously." ' students, and a shortage of physicians, at least in the rural districts. In the progress of medical science and prac- tice, which has been most gratifying, THE PROBLEM OF A CLINICAL the future of the two years schools may iv/iE^r*! r^-A T crunnr tm mhrth be a matter of purely academic interest, MEDICAL SCHOOL IN NORTH ^^^ .^^ ^^^ p^^^^^^ ^^ ^^^ adequate sup- CAROLINA* ply of physicians the expansion of such schools may be a matter of vital im- liy Dr. I. II. .Manninii. ciiapd Hill. N. I"., portance in their respective localities. The advancement of the entrance re- The problem of a clinical medical quirements and the increasing cost of a school in North Carolina has been in the medical education have not suppressed background for a number of years. In the desire of our college students to 1890, after the medical schools began to enter the field of medicine. There are offer a three-year course and to arrange more students preparing to study medi- the subjects in a more orderly sequence, cine than ever before and as our col- the University of North Carolina, as did leges grow the number will continue to many colleges and universities, estab- increase. Their problem is to get into lished a Medical Department, offering a medical school. I am told that one the subjects of the first year. Later, of our large eastern schools refused as the better type of schools began to admission to one hundred and fifty ap- offer a four-year course the one-year plicants last fall and I am quite sure schools extended the course to include all of the medical schools admitted to the subjects of the first two years, the their full capacity and refused many. so-called laboratory subjects. Eleven The shortage of physicians is clearly of the two-year schools are now in ex- not due to a lack of men wishing and istence. fully qualified to enter the profession. From time to time with the progress The opportunity is being limited. of medical education conditions have The limitation of enrollments has developed which, for the moment, at been necessitated by the introduction of least, have seemed to threaten the fu- the laboratory method into the teach- ture of this type of school. In the be- ing of the clinical as well as the pre- ginning a refusal to accept their stu- clinical subjects. The capacity of the dents for advanced standing was the laboratory and the facilities for indi- threat, later the advancing entrance vidual or small group instruction in the requirements, and now the limitation of clinic determine the capacity of the enrollment and the tendency to intro- school. In a survey made by the Coun- duce clinical subjects into the curricu- cil on Medical Education of the Ameri- lum of the first two years. Obviously can Medical Association the total capac- should the time arrive when it becomes ity of the sixty-six Class A schools was impossible to transfer students to de- found to be 15,925, and by certain minor changes this number could be increased •llcail lu-fovr I lie Wilis! Dii-Salcm mooting to 17,425. The total number of gradu- of tho Noi'lh Caidliiia Medical Sociely. April ates that may be expected from this en- 25-26-27, i'.)22. rollment is about 4,000 per year. From SOUTHERN MEDICINE AND SURGERY June, 1922 such a statistical study one may reach the conclusion that even with the limi- tation of enrollment we have an ade- quate number of medical schools in this country. A statistical study will also demon- strate that the ratio of physicians to the population throughout the country is 1 to 720 and doubtless our cities are over- crowded, but these facts do not quiet the general chorus from the country nor satisfy the proper demands of a large and important element in our na- tional life, the rural population. North Carolina has a population of 2,559,123 and 1,600 physicians in active practice, a ratio of 1 to 1,600. The drift from the country to the city has affected all classes irrespective of occupation and, one may venture to predict, will con- tinue until rural life affords comforts and opportunities approaching in some degree those to be had in the city. Our medical graduates with their educa- tional background and scientific train- ing are not content with the limitations of the country and one must sympa- thize with their point of view. More- over, the country practice is essentially a general practice and the undergradu- ates have heard so much of the difficul- ties of professional advancement except in restricted fields that the general practice has become unattractive. North Carolina is essentially a rural state; there is a drift from the rural districts to the towns within the State and from the State to the cities of other States. From a group of 568 students who have attended the University Medical School and whose addresses are known, 167, or 27.6 per cent, are practicing outside of the State. Of the 814 applicants licensed by the State Board of Medical Examin- ers from 1910 to 1919, inclusive, we have calculated that 185, or 22.7 per cent, did not practice in the State. There has therefore been a drift out of the State of approximately 25 per cent. The establishment of a clinical school of a medical school tend to locate in its vicinity. Whether or not this is a de- monstrable fact I am unable to say, but in looking over the list of our own stu- dents who have settled outside of the State I find that there are twenty-one practicing in Pennsylvania and New Jersey, all graduates of the medical schools of Philadelphia. Aside from any advantages that may accrue from the location of a school within the State, I think we shall agree that the physi- cians who will practice in the country must have come from the country, and I am quite sure that the physicians who will practice in North Carolina must have come in lar,'je measure from North Carolina. Can we depend upon the schools of other States to provide an education for our own doctors? The cost of a medical education is approxi- mately four times the receipts from the fees paid by students. Is this not too large a contribution to expect from other States? The problem of establishing a clinical school in North Carolina is more com- plex than perhaps you may imagine. I am quite sure that in spite of the in- dependence of the average unrecon- structed North Carolinian and his re- sentment of any interference from the outside in the conduct of his affairs one will realize that no educational institu- tion can set up for itself standards markedly at variance with the stand- ards prevailing throughout the country. I do not believe the physicians of the State will support an institution whose standards are markedly below the ac- cepted level. I assume, therefore, that we must have a first class school or none. There may be wide variations in our conception of a Class A school. Certain- ly if one looks over the list of the sixty-six existing in this country very great differences, in certain respects at least, may be observed. It is mosr gratifying that enormous funds are be- ing expended at some of these institu- tions for the advancements of medical will, we believe, tend to provide an ade- education and medical science and we quate supply of physicians for the State, may covet for North Carolina a Har- There is an impression that graduates vard, a Michigan, or a Cincinnati, but June, 1922 ORIGINAL COMMUNICATIONS we are not entertaining any grandiose delusions at this time. If this type of school is an ultimatum the situation is hopeless. However, there are certain fundamentals, certain essentials, which are indispensable. At the outset we must recognize the two functions of a medical school : First and primarily, the training of students for the practice of medicine; and sec- ond and secondarily, the advancement of our knowledge of medical science. I feel sure these dual functions are generally accepted but in practice, and certainly in the minds of some teachers, the or- der of emphasis is reversed. However, the medical school that does not pro- vide for both teaching and research in the selection of its faculty and equip- ment is doomed to mediocrity if not failure. The teaching of clinical medicine has made rapid progress within the past few years. The didactic system has given place very largely to bedside in- struction, an improvement for which we should be devoutly thankful. Who has ever learned to recognize a crepi- tant rale, a pericardial or a pleuritic friction sound from the back bench of an amphitheatre? A pre-requisite to the establishment of a clinical school therefore, is a hospital of such capacity as will furnish a sufficient variety of clinical material for teaching purposes and provide such equipment and labor- atory space as is required in the teach- ing and practice of modern medicine. I wish to emphasize the three essentials: First, a hospital of sufficient bed ca- pacity ; second, clinical material of suf- ficient variety available for teaching purposes ; and third, equipment for the teaching of modern medicine. This is the real problem in the establishment of a clinical school in North Carolina. In the large cities there are such a number of hospitals and such a wealth of clinical material that one may im- agine the problem for a school so for- tunately located to be very easy of so- lution, and yet a municipally-owned and controlled hospital, or one privately endowed and controlled by an independ- ent board of directors, is far from satis- factory for teaching purposes. The construction and maintenance of a hos- pital which is primarily for the care of the sick is unquestionably a munici- pal function, if not an obligation, but it is equally true that a hospital for teaching purposes must be absolutely and unequivocally controlled by the medical school. The control of the hos- pital by the medical school is not in the least inconsistent with its primary pur- pose; on the contrary, such control will bring to the sick the very best medical service that can be assembled in the fac- ulty of the school. In a rural State such as North Caro- lina, in which there are no large cities and in which the clinical material is scattered over a relatively large area, the problem is far more difficult. Is the large city hospital an essential, a sine qua non, or does it not depend after all upon the character of the work done? Of the latter we have abundant evidence in the marvelous success of the Mayo Clinic, of the University of Michigan, the University of Iowa, and of our own Sanatorium for Tuberculo- sis, all of which are located in relatively small towns. I do not question a suffi- cient supply of clinical material in a properly conducted hospital convenient- ly located in North Carolina. The construction and maintenance of a sufficiently large hospital is an ex- pensive undertaking. We have recently sent a questionnaire to certain univer- sities and hospitals where the data on the cost of construction and mainte- nance could be based on some fairly up-to-date experience and we have found the cost of construction to be in the majority of instances between $3,- 000.00 and $4,000.00 per bed and the maintenance quite uniformly around $3.50 per bed per day. These figures are based on the supposition of fireproof construction with a reasonable space al- lowed for laboratory and teaching pur- poses. In 1915 a committee appointed by the Council on Medical Education to sug- gest plans for a reorganization of the teaching of clinical medicine recom- mended that a medical school should 314 SOUTHERN MEDICINE AND SURGERY June, 1922 have a hospital with a minimum capac- very much increased, ity of two hundred beds. There are (3) From State funds. In a rural only two schools of the Class A group State such as North Carolina, where with substantially less. In the south- there are no large and wealthy munici- ern group we find the University of palities, the State must be expected to Texas at Galveston has 316 beds, the provide the funds for such an enter- University of Georgia at Augusta 250 prise. This view has been taken in a beds, the State Medical College of South number of States, some essentially like Carolina at Charleston 248 beds, the North Carolina and others with large University of Virginia at Charlottesville cities. The most illuminating illustra- 200 beds, the University of Tennessee tion is perhaps Iowa. In 1897 a State- at Memphis (in the two hospitals in supported general hospital was built at which it has teaching privileges) about the University in Iowa City, which has 500 beds. Should we undertake the es- at this time a population of less than tablshment of a clinical school with less 12,000, primarily for the purpose of the than a 200-bed hospital? Conservatism medical school. From time to time ad- might suggest that we begin on a smal- ditions have been made until now there ler scale and enlarge as the experiment is a total of 650 beds in the University succeeds, but would not the experiment Hospital. Iowa has a population of ap- be doomed to failure at its outset ? proximately two and one-quarter million Accepting for the moment the more (North Carolina two and one-half mil- ambitious plan, the next problem is to lion), its largest city, Sioux City, has a obtain the funds with which to con- population of 71,227; and the amount struct and maintain such a hospital, of its agricultural and manufacturing This problem may be met in various wealth is about the same as North Car- ways: olina (its agricultural wealth is much (1) By private endowment. Since greater its manufacturing wealth as vast sums of money have been donated much less). Michigan is perhaps the in recent years for the purpose of medi- most striking illustration of the success cal education, there has been a general of such an enterprise. The State has feeling that we may look to this source at Ann Arbor, a town of less than 20,- for all or a part of the funds for our 000, a University Hospital with 400 beds purpose. It is idle, in my judgment, and is at the present time building an to expect help from this quarter until addition of 600 beds at a cost of $3,- we have done something in a very sub- 500,000. We are informed that Wiscon- stantial way for ourselves. North Caro- sin will build at Madison, a town of lina should not be regarded an object of about 38,000, a University Hospital to charity. cost $1,500,000 or more. (Incidentally, (2) From municipal funds. Dr. Bev- there is already a general hospital in ans, chairman of the Council on Medi- Madison with a capacity of 115 beds, but cal Education, regards the construction the University of Wisconsin has not and maintenance of a hospital as alto- thought it wise to expand its medical gether a municipal function, and this course into a full four-year course.) opinion is shared by many medical edu- The idea of a State-supported general cators and in practice by the majority hospital appears to be growing in pop- of medical schools. It has been very ularity in the middle and far west difficult to get and retain such control where public policies are unhampered as the school should have over munici- by traditions and new ideas may be pally-owned hospitals (Cincinnati is a tried out in a new soil. brilliant exception), and under other I do not mean to suggest by reference conditions they are unsatisfactory. In to the above instance that in the event view of this, the feeling is growing the State should build a hospital it that the school should own and control should be located in Chapel Hill. In re- its own hospital. But obviously the ex- spect to this point there are divergent pense of maintaing the school will be views in so far as medical opinion is June, 1922 ORIGINAL COMMUNICATIONS 315 concerned. When it so happens that the icipal and privately-owned hospitals University is favorably located there and such a state-supported hospital as can be no question of the desirability has been projected. It would appear, of locating the medical school near the however, that such institutions would University. Var.derbilt will spend quite be amply protected by the fourth clause a large sum to move its school across in the Michigan regulations, viz., "All the city of Nashville. Tulane is trying per.sons bringing letters to the super- to raise funds for the same purpose, intendent recommending admission Quite a number of universities, how- from their usual medical attedant." ever, have placed the medical school in This places the matter in the hands of cities where it is believed clinical mate- the physicians practicing within the rial is more easily obtained. The Uni- State. There are a large number of versify of Colorado is perhaps the last charity and semi-charity patients in one to consolidate its school at Denver, need of hospital attention who cannot It has spent for what the dean describes be regarded as a source of revenue to as a modest beginning $1,500,000. Cor- any hospital. The daily average of beds nell has its medical school in New York occupied in the hospitals from which City, the University of Texas at Calves- records are obtainable is 61.77 per cent, ton, the University of Georgia at Au- Is it not from the fact that many of gusta. Harvard College is in Cambridge, our sick are unable to meet the hos- the Harvard Medical School in Boston, pital charges? An additional hospital Perhaps you will be more interested in of 200 beds will make very little im- the conduct of the hospital than in its pression upon this group of patients, location. At the University of Michi- Should such a hospital be restricted gan patients are admitted under the to semi-charity and charity patients? If following regulations: so, how shall it be supported? At the 1. Those whose admission is provid- rate of $3.50 a bed per day we may eas- ed for by special statute, or patients ily calculate the cost of maintenance to sent on order of the Superintendent of total about $250,000 per year. Should the Poor, supervisor, or city official, we make a uniform charge for those being authorized to issue such an order, who can pay and collect it from the 2. Emergency cases. patient and no charge to the indigent 3. All students in actual attendance and ask the State to pay it? The latter at the University and at the Michigan plan seems to be in practice in the Uni- State Normal College. versity of Michigan. The state, how- 4. All persons bringing letters to the ever, has the right to collect from the superintendent recommending their ad- county from which the patient comes, mission from their usual medical at- Iowa allows the hospital $3.50 a bed tendant. per day. The University of Michigan 5. Persons not included in the above reported in its financial statement for four classes in accordance with rules the year 1921 a net profit of about $27,- prescribed by the regents may register 000 on its hospital accounts. for an examination and admission by The problem before us is the con- making an affidavit to the effect that struction and maintenance of a 200-bed they are unable to pay the minimum hospital, built and supported by ^he fee of the profession for such medical state, and controlled by the medical or surgical service as may be required, school. Such a hospital would con- 6. Private patients for surgical, med- tribute in large measure towards an ical, and X-ray departments. adequate medical service for the people In my own judgment, the latter group of the state not only directly, but by should be omitted or indicated under 4. graduating each year a large propor- Would the profession of North Carolina tion of the physicians required by the support a hospital conducted in accord state. Can we persuade the legislature with such regulations? to make the necessary appropriation? One may foresee some competition, Will the doctors support the proposi- some rivalry perhaps, between the mun- tion ? 316 SOUTHERN MEDICINE AND SURGERY June, 1922 SOUTHERN MEDICINE AND SURGERY r^-^^tS tatinf LTpitar"^: Published Monthly by the where in the country is there probably Charlotte MedicaiJournal Company ^ "^^^^c^^ situation more clearly de- manding attention, and the development M. L. TOWNSEND, M. D. , ^^.^^^^ of the University Medical School would J. c. /iJONTGOMERY, M. D. ( ' «"■« ^^ ^ distinct forward step in safeguard- CHARLOTTE. N. c. ing the health of the people of the state. All these facts point to the same con- ,,„ , , ^ . J- . J t ^ .. elusions — a four-year medical course as "Read not to contradict and confute, nor to ^ j' .-, n • ■, „ believe and take for granted, nor to find talk a part of the University. and discourse, but to weigh and consider." — The question of the location in the Francis Bacon. state of this finishing medical school "•— " with its accompanying hospital is one A FINISHING MEDICAL SCHOOL which must be decided with one idea FOR NORTH CAROLINA. solely in view, that is where it will ren- der to the people it is meant to serve Some months ago a committee was the greatest possible good and where its appointed consisting of Dr. Chase, Presi- students will obtain the maximum ad- dent of the University, Dr. Manning, vantage from its clinical material. Dean of the Medical School, and Dr. The dominant thought and motive is of Richard H. Lewis, to investigate the ex- course a teaching institution,— a medi- isting conditions relative to the estab- cal school and as such it must be located lishment by the State University of a where are available medical men for full and complete class "A" Medical teachers, and where the greatest num- School for North Carolina. ber of patients for clinical purposes will This committee has made a most be the most accessible, careful and extensive investigation and This proposition, of such tremendous- have rendered to the executive com- ]y vital importance, must never for one mittee of the University a 5,000-word moment be thought of as a temporary report, recommending that the present "lean to" or side-roofed shed set up two-year course be expanded to the full against some existing institution or four-year course and that in connection place, but it must be builded for genera- with this school the necesary hospital tions yet unborn. This must be the be built at a cost of approximately foundation upon which will be built an three-quarters of a million dollars. institution whose influence will be felt The Executive Committee of the permanently. Board of Trustees unanimously endors- Nothing is needed more today in ed this report and requested some fur- j^To^h Carolina than this thorough and ther investigation and the outline of a complete medical school, but clear vision definite plan of proceedure to be sub- j^ necessary and the ultimate goal must mitted to the full Board at the October ^^^ ^^ obscured by any thought of meeting, and if the plan is finally ap- idealized gain or personal agrandize- proved it will be laid before the budget j^gj^^. commission of the General Assembly in ' "" Thfreport as adopted summarizes as ^ISSOT GASOMETER INSTALLED follows: AT STATE SANATORIUM. "It is clear, therefore, that all three The North Carolina Sanatorium for facts — the shortage of physicians in the treatment of Tuberculosis, at Sanator- state, the lack of adequate hospital ium, has just installed a Tissot Gaso- facilities in North Carolina, and the in- meter with its accompanying Haldane creasing nifTiculty of maintaining a two- gas analysis apparatus, all of which is year medical school, all point to the ex- of the Bouthby (Mayo Clinic) specifica- pansion of the school into a full four- tion and standard. This complete ap- June, 1922 EDITORIAL 317 paratus is the very last word in the regarding the specificity of tuberculosis determination of the basal metabolic and the advancement of theories that rate. almost any bateria, whether cocci or The Sanatorium staff are daily con- bacillus, when placed in the proper fronted with the most intricate prob- media and environment, will become a lems along this line — that is the differ- tubercle bacillus, are we going to find entiation of incipient tuberculosis from that the symptom complex known as mild ovarian disease or mild hyper or tuberculosis will be proven to be nri- hypothyroidism or some low grade focal marily either a nutritional or an endo- infection without definite symptoms, re- crine disturbance, which produces the lating to the anatomy involved. proper soil and stimulus for the meta- Such cases require the most refined morphosis of an everpresent bacteria technique and the most complete appar- into a tubercle baccillus, which after all atus obtainable in order to render to the is only incidental and secondary to the people affected and the profession of the real pathology. state the service which an institution of that sort should render. CRIMINALITY. With this new Tissot apparatus the ^ ,^ ^^ ^ ^ xt ^u r^ ' r doctors at the Sanatorium will now be I" the State of North Carolma a corn- able to make a thorough and detailed mittee of one hundred representative study of the nitrogen balance in pulmo- citizens, men and women throughout nory tuberculosis. the state, has been named for the pur- The consideration of this subject pre- Po^e of studying the momentous prob- cipitates a most interesting question lem of the care and treatment by the which only the free use of Gasometer state of those wards of the state who apparatus can solve, viz., in the presence have been classified as criminals, of a low grade chronic infection, is it Certainly with all of the state's giant not possible and probable that there is strides forward toward the goal of prog- an increased cellular activity through- ress and a better civilization, no prob- out the body due to the increased de- lem can be more far-reaching than the mand by the individual bodv cells for problem of properly handling those m- thvroxin that thev mav maintain this dividuals who have failed to recognize increased phvsiologic rate of intra-cel- the rights of others and have violated lular metabolism ? And in such case is the laws of the people promulgated for it not possible that before the thyroid the government and well-being of the gland responds to this increased demand state. made upon it there is a hypothyroxin- The laws of God (Nature and God ism, which clinically would be called are one) are inexorable. There is not hypothyroidism? Then, later, when one law of nature but that has attach- the thvroid compensates for this in- ed to it a sure penalty for its violation, creased demand why might we not get But the laws of Omniscience cannot be a hyperthvroxinism by (1), a decreased questioned, for they are just. Being the demand by the cells of the body and (2), laws of omnipotent Omniscience man by the more than sufficient confoensa- cannot change them and must abide by tion of the thyroid. them— either obey them or pay the We happen to know that this is one, penalty, among many problems, which vitally in- The violators of these fundamental terests the staff at the Sanatorium and and unchangeable laws of God are not now with the acquisition of this most however, always called criminals. This valuable and complete equipment to aid name is reserved for application to them, we may expect some important those who violate man's laws, and ob- contributions toward the solution of the viously laws made by man can be no problem of accurate diagnosis of incip- more perfect than is man himself, ient tuberculosis. Two persons have never lived whose With the present revolutionizing ideas mental processes ran absolutely parallel 318 SOUTHERN MEDICINE AND SURGERY June, 1922 — there is always the individuality and dividual is as futile as to slap the waves the personal viewpoint. The interpre- to quiet them. The term "criminal in- tation of man's laws and the applica- sane" is perfectly alright and proper tion of man fixed penalties is produc- when used to describe a person whose tive of many mistakes and injustices. insanity leads to the commission of acts The purpose of any law, whether which would be criminal if committed nature's law or man's law, and the ap- by another but m the strict and accu- plication of a penalty for its violation, rate sense there can be no such thmg can only be to make things better. The as criminal insane. Such a person is laws of the state are good— they are either criminal or he is insane, but he the best that man has been able to cannot be both. make. In the eternal scheme of things And this is one of the most vitally — in this never-ceasing evolution, man important questions this committee must is permitted to catch new visions of consider. North Carolina is cursed to- better things, hence it is eminently day because of her lethargy in deter- right and proper that in the light of mining whether this man is insane or added knowledge and increased under- is a criminal. She is doubly cursed be- standing old laws should become obso- cause, not being in a position to deter- lete and should be supplanted by others mine this fundamental question, she has which conform to these higher stand- made use of the ambiguous term, "crim- ards. inal insane," and has chucked every As in all lines of human activity there menace to society into a prison cell. In- have been, and are constantly, many consistent? Yes, extremely so! and oh, changes in the manner of penalizing consistency thou art a jewel, those who violate man's laws so that In the months gone by we have had the world believes it is doing this today occasion in these same columns to ad- much better than in times past. And vocate a Governors Advisory Board, yet with all these changes we are still whose duty it will be to investigate the not up to date, and have not caught up mental responsibility of every so-called with our expanded capacity for seeing criminal in the state and report its find- and understanding. ings to the Governor, to the end that The appointment of this committee justice may be done. Every day this is, of itself, prima facia evidence that is delayed is adding one more day of the state realizes this situation and cruel injustice to many and at the same realizing it, cannot condone it but must time is adding one more day of compar- make improvements. ative freedom to many who should pay We are, in too many instances, hold- ^he penalty for their crimes, ing on to forms and customs which The condition today of those wards were the best men knew, in the light of ^^ ^lie state who are classified as crim- the times when they were promulgated, ^^al insane is an abomination in the but which have since been proven incor- sight of the Lord and a disgrace to the rect and unjust. These obsolete forms state. and customs must be abolished— must The old adage of "Hew to the line be supplanted by those which conform to and let the chips fall where they may," our present day vision and understand- is noble and fine— but when these chips ing. An insane man cannot commit fall in a neighbors yard and clutter it crime, even though his insane acts up then an injustice is done. Hewing would, at the hand of a sane person, be to the line is the proper spirit, but also the most atrocious crime. For the in- there must be some accounting of where sane it cannot be crime, because from the chips may fly. A criminal should, by the insane mind has been taken away all that is holy, be fittingly punished, the knowle-ifre of good and evil and he but if, in order to punish the criminal, is no longer able to discern between an innocent wife and helpless babies are right and wrong. To punish such an in- left without bread and protection, then June. 1922 EDITORIAL 319 an injustice is done and a state is guilty, enlargement of the thyroid in a person Absolutely inexcusably guilty in the over thirty years of age should lead one light of Christian civilization. Here the to suspect carcinoma, especially if the state must draw fine lines and use keen gro\\i:h is of firm consistency. discretion, but the blood of a host of innocent is spattered all over the state. Observations on the Diagnosis and Treatment of Toxic Goiter. L. Wallace Frank, Internat. J. Surg. Dec, 1921. SURGERY In all cases of tachycardia, nervous- A. E. Baker, M. D., Dept. Editor "^^s and muscular weakness an exami- nation of the thyroid gland should be '■f made, to rule out the possibility of a (We regret that inadvertently we failed to toxic goiter. Exophthalmos is a vari- make the correction on the front cover page ^^le symptom. Occasionally a subster- Fhowing Dr. Bakers name as Editor of the i -4. -ii j. • j. Department of Surgery. We are. however. "^^ ^O^^er Will caUSe toXlC Symptoms, very proud to have Dr. Baker join hands with and the diagnosis can be made only by the staff and help make Southern Medicine means of the fluroSCOpe. The basal and Surgery the cleanest and most helpful metabolism is of great value in deter- mfdical publication in the South. Dr. Baker . . -i j £■,•>• needs no introduction, for he and his work are "^1"!"^ ^lie degree of mtoxication, aS well known to every doctor in the Caroiinas are also diarrhea and spontaneous sem- and Virginia. His contributions in this de inal emissions. In actual practice, ac- partment will he authentic and of great ser- cording to Boothby, 95 per cent of vice to all readers.-Editor.) patients with increased metabolism have The Milignant Degeneration of Benign hyperthyroidism. Clinically, this has Tumors of the Thyroid Gland. been the author's experience, and has John Speese and Henry P. Brown, Ann. Surg., ^f^gn helped to differentiate toxic from Dec, 1921. nontoxic goiter, but it is not so useful In the material examined for. this in determining the treatment best suited paper in 426 lesions cancer occurred 19 to the case. The adrenalin chlorid times and sarcoma 3 times and with 6 (Goetsch) test is still in the controver- cancer cases from outside sources; 28 sial stage. Peabody and others found malignant thyroid tumors in all. Can- that 50 per cent of cases of "effort syn- cer was found to be associated with 10 drome" responded positively to the adenomas, 4 fetal adenomas, 3 papillary test, and that 14 per cent of normal in- cyst-adenomas and 5 colloid goiters, dividuals also gave positive results. In There were therefore 78.5 per cent of 21 cases of hyperthyroidism there were cancer cases with preexisting pathology positive reactions in only 15 cases. To in the thyroid which had been present treat a toxic case most efficiently, co- on an average of twelve and six-tenths operation between the surgeon and the years. internist is most necessary. One should The diagnosis before operation is dif- look for tonsillar or oral infections. Thy- ficult, the majority of cases only being roidectomy, when possible, is the treat- discovered after operation during histo- ment of choice. Roengenotherapy is of logic examination of the tumor. Clini- doubtful value, the benefits continue as cally an increase in size and consistency long as treatment is given, but relapses of growth were the first symptoms are common. noted. The number of cures depended upon the early removal of the cancer, Factors Influencing the Rate of Mor- but complete removal of the thyroid is tality in Surgery of the Thyroid not necessary when the disease has not Gland. spread beyond the capsule. In Balfour's ^- ^^- Batcheior. New Orleans, m. e. s. j., series there were 35 per cent without "^^°' ^^^2. recurrences, 11 with recurrences, 47.6 The condition of the patient at the dead of recurrences and an operative time of operation is determined by the mortality of 6 per cent. Asymmetrical measures employed during the prepara- 320 SOUTHERN MEDICINE AND SURGERY June, 1922 tory stage of treatment. At this time week, measure the abdomen at the naval, the mortality rate may be said to be measure the chest — at rest, at inspira- fixed, for the outcome of the case must tion and at expiration — and record depend on the wisdom and care display- these. ed by the surgeon in the adoption of Exercise in a room that is airy — in methods for rebuilding the exhausted winter, one that is cool but not shivery, organism and erecting barriers against Have a clock in plain sight and exercise the stress of a serious surgical opera- by time. Begin with 5 minutes night tion. Thyroid cases that come to the and morning and increase to at least 20 surgeon for operation are no longer minutes each day. Do not over do it merely cases of thyroid gland disease, the first few days and give it up the There is a general cell sickness. Often second week. acetone and diacetic acid are present in When possible, other exercises should the urine. In exopthalmic goiter there supplement these — golf, tennis, and are periods of exacerbation and of re- walking. Motoring is not included, mission, vomiting, and rejection of All exercises to be done slowly and fluids, so that the tissues become in a with resistance by the opposing muscles, measure dehydrated and alkalinity of Exercise before a mirror and try to the blood is often lessened to the point stand correctly and to keep the body of acidosis. The metabolic rate is high. taut. Wear loose clothing — a one-piece The patient approaching a period of ex- bathing suit is comfortable, acrebation is not as good a risk as one How to stand. Heels together, toes with a higher metabolic tests to be on out, legs straight, chin up. Do not try the ebbing wave. No regimen can be to "hold the shoulders back" ; take a too elaborate and the surgeon who deep breath filling the chest, and hold neglects the most trivial detail in the the chest in this position and the survey and treatment of the patient shoulders will be correctly held. Hold prior to operation is building up for the abdomen in. This is the starting himself an unenviable operative mortal- position and will be assumed after each ity. In those cases that are approach- standing exercise. ing the terminal stage with evidence of Take six deep breaths between each decompensated heart, extreme brain two exercises. sensitization and all the other symto- 1- Inhale slowly and at the same time matic evidences of the ravages of super raise the arms from the side till the thyroidism, the type of anaesthetic be- hands are over head, stretch up, raising comes of foremost importance. Crile on the toes and reaching up with the has definitely ruled out ether and has fingers — trying to increase the reach adopted the combined nitrous-oxid anal- and to take in more air. Exhale slowly, gesia with local anaesthesia. bringing the arms down to the sides. ^ Repeat three times. 2. Hands on hips, fingers to the front, elbows back. Bend forward from the hips until the right angle is reached, then back as far as possible', six times. Exercises Recommended By Dr. Robert ,^-.^^^f'P ^^^",^% ^^^'^ ,^"f ' ,^^^^^« E. Seibels, Columbia, S. C. '\'^f^^' ^^""t ^^^^^^ f^^^^ ^"/ slowly revolve the body on the hips, to These exercises are designed to build the left, rear, right and front, three up the musculature in general and that times. of the abdomen in particular. The bene- 4. Hands on hips. Sit down on heels fit derived will depend on the regularity with the body erect and lift on toes with with which they are performed and the the knees wide apart. Bend forward, vigor put into them. The results may pressing the body against the knees. be measured directly by recording the Rise to standing position, three times. changes in the body. Weigh once a 5. Lie on back on floor. Fold the Gynecology and Obstetrics Robert E. Seibels, M. D., Dept. Editor June, 1922 EDITORIAL 321 arms over the chest. Raise the right out of commission by ligating its ureter, leg with the knees straight, keeping the the opposite one hypertrophied readily other heel and the head on the floor, and suffciently to take care of the secre- Lower and repeat with the other leg. tion formerly done by the two organs. With each leg three times. The blood nitrogen was not greatly 6. While on the back, fold the arms, changed during this readjustment and keep the legs straight, rise slowly to no marked system disturbance occurred, sitting position and slowly back, six If the ureteral obstruction had existed times. for as much as forty days, a certain 7. Turn over on the abdomen. Place amount of function would be restored on the hands on the floor near the shoul- its release but the hypertrophied kidney ders and with the body held straight, would continue to do the work and the raise up so that the weight rests on the other continue to atrophy until it entire- toes and hands ; lower down to but do ly ceased to function. In other words, not touch the floor, three times. his work shows that the parity of fhe After these exercises have been done two kidneys must be kept fairly close or a few times so that they can be done the hypertrophied one will gradually put easily, increase the number of times the weaker one out of commission, each is done until the allotted time is This is of practical value in determin- taken up. ing the advisability of nephrectomy in Knee-chest exercise. Twice a day, cases of one healthy and one diseased before arising and after retiring. The •^•^"ey from whatever cause. This de- head rests on a pillow, the chest is monstrates the importance of carefully brought as close as possible to the bed investigating every case of "surgical and the legs are drawn up so that the kJ^ney" before operation. In cases of hips are as high as possible, the weight nephritic or ureteral stone with or with- resting on the knees and chest. Keep ""t infection if the various functional thighs vertical. Relax the abdominal tests show that they are greatly out of muscles and take 12 slow, deep breaths, balance, the diseased one should be re- moved instead of doing a nephrolitho- Urology A. J. Crowell, M. D., Dept. Editor Dr. John T. Geragthy of Baltimore, at the meeting of the Gernito-Urinary ^ Surgeons Association in Washington, and Dr. Arthur B. Cecil at the American The editor of this department of the Medical Association meeting, in St. Journal was privileged to witness some Louis, in their papers on modifications of the experimental work on kidney of Young's perineal prostatectomy, mark functional activity now being done by a revival of interest in the perineal Dr. Richards and Wearn at the Univer- operation. The fact that this operation sity of Pennsylvania on his recent visit stood unchanged or unmodified for to Philadelphia during the American twenty years is a wonderful compliment Urological Association there and at to its originator. Few operations have Atlantic City. It was the most wonder- stood, without the suggestion of a modi- ful research work he has ever witnessed, fication, for so long a time. A report of this work will soon be Working independently and without in print and I would advise all who are any knowledge of the others work, they interested to study it carefully. were designing an operation to better Dr. Hinman's report of the results he preserve the external sphincter muscle obtained in his experimental hydrone- and membranous urethra. In this way phrosis in rats, guinea pigs, and dogs at they hope to overcome the incontinence the Genito-Urinary Surgeons Associa- which occasionally follows Young's oper- tion at Washington, D. C, May 1st and ation for a short time. They advocate 2nd, was an outstanding contribution. removing the gland without making an He showed that if one kidney was put opening into the membranous urethra SOUTHERN MEDICINE AND SURGERY June, 1922 by freeing the gland and splitting the capsule transversely for enucleation. The gland is removed "en masse" and the opening into the bladder effected through the prostatic urethra. We believe great care should be taken to preserve the membranous urethra and external sphincter and that the emphasis laid upon it by these men will result in great good. Mental and Nervous James K. Hall, M. D., Dept. Editor The Atlantic Monthly for June con- tains an article by Ellen N. LaMotte which every member of the medical pro- fession should read. It is entitled "America and the Opium Trade." Atten- tion is directed first to a pamphlet is- sued in 1919 by the Public Health ser- vice in which the statement was made that the United States is the greatest opium-consuming country in the world. In this country the per capita consump- tion is 36 grains ; in Italy the per capita consumption is 1 grain; in Germany 2; and in France it is 3 grains per annum. The Treasury Department's report, "The Traffic in Narcotic Drugs," issued a year before national prohibition became effective, gives interesting information about the use of morphia by addicts in New York City alone. Five-sixths of the addicts contracted the habit before reaching the age of twenty-five. The New York Drug Clinic offered free treatment to addicts in a hospital on North Brother Island. After several weeks treatment, when restoration to their normal habits might have seemed reasonably assured, they were discharg- ed and sent back to the city. Within twenty-four hours 90 per cent of the so- called recoveries had resumed the use of the drug. Why this immediate relapse? Be- cause each former addict is trailed by a member of the opium-selling gang, and is induced to resume the use of the drug. The writer then calls attention to the world-wide organization that con- trols the bootlegging activites in opium and in opium-derivatives. This traffic has its origin in the overproduction of opium in the world, and most of this production takes place in the British tropical possessions — chiefly in India. The statement is made that the British Government not only allows, but that it actually encourages, the illegal traffic in opium by stimulating overproduction. In India, for instance, where most of the world's opium is producerd, every step of its production, manufacture, and dis- tribution is under government control. The poppy crop is collected by a govern- ment agency, it is transported by this agency to a government factory, where it is manufactured into two classes of opium — one class fitted for export, and the other for home consumption. Once a month, at Calcutta, the British-India Government sells at auction to the high- est bidder its chests of opium. From this source, and from this source almost alone, all the opium used by addicts throughout the world finds its way from the producer to the pipe, to the mouth, or to the hypodermic syringe of the habitue. It is to be remembered that in many of the British possessions shops are licensed for the sale and distribu- tion of opium. In India alone there are 17,000 licensed smoking-rooms. The purpose of the British Government in exercising control over the production, manufacture, and distribution of IJhe drug apparently is not to prevent its un- necessary use, but the sole object seems to be to make money for the govern- ment out of the nasty and indefensible business. It is estimated that one ton of opium would supply the legitimate needs of North and South America each year; another ton would supply Europe, and another ton Asia. Three tons would be medically sufficient each year for the world, if the supply to addicts was stop- ped. But in the British possessions alone, under strict government licensing and control, almost 1,300 tons are pro- duced and distributed throughout the world each year. The reader must bear in mind that of all this opium — of all these tons — only 3 tons find legitimate medical use in the world. June, 1922 EDITORIAL 323 The Opium Section of the League of Nations, called to meet in Geneva this very spring, had for its sole object the purpose of bringing under control throughout the world the production, manufacture, and distribution of opium. The British Government may try to keep its dependencies from under the in- fluences of the operation of the League by the assumption that the League has no control over dependencies. It seems strange, even foolish, that the Govern- ment of the United States should be spending millions and millions of dollars to suppress the illegitimate use of opium, that physicians and nurses should be wearing themselves out year after year in the treatment of addicts, and that countless individuals should be made wretched and miserable, often hopeless economic and moral outcasts, because of their use of opium, in order that the British-India Government may reap rich taxes from opium-production and opium-sales. Has the time not come when the United States Govern- ment should make representation to the British Government about this very matter? Let Great Britain be left to answer at the bar of her own conscience for the production and the fostering of drug addiction amongst millions of her own subjects, but let her be told that the time has come when she shall no longer destroy the happiness and the lives of millions of American citizens. Deadly diseases are not admitted to the United States. Why should substances the im- proper use of which begets conditions worse than diseases — yea, worse than death itself — be admitted? Orthopaedics Alonzo Myers, M. D., Dept. Editor Process of Lumbar Vertebra. .Tdunial of Bone and Joint Surgery, Boston, April, 1922, 4, No. 2. Pain in the left thigh and lumbar region was the chief symptom in Moore's case. It had come on suddenly about four months previously while the pa- tient was doing some light work at a grinding machine. There had been no unusual strain nor could he recall any trauma. The pain at the onset was so severe that he was unable to stand or walk, but this severe pain gradually left, and was replaced by a dull aching pain which persisted. A few weeks after the onset, the left thigh and leg became weaker than the right. The pain ra- diated down the inner side of the thigh to the knee. In the left lumbar mus- cles there was a swelling near the spi- nous processes, which gave deep fluc- tuation but was only slightly tender. The entire spine showed a slight list to the right. Forward, backward and lat- eral bending all caused severe pain which radiated down the thigh. Lat- eral bending to the right caused spe- cially severe pain. Both hips and knees showed normal motion, passively. Ac- tive flexion of the left hip, especially against some resistance, caused severe pain both in the back and the thigh. The left thigh was one inch smaller than the right and the calf was three- quarters of an inch smaller than the right. There was decidedly less strength in the muscles of the left thigh and leg. The roentgen ray showed the entire transverse process on the left side of the third lumbar vertebra separated from the vertebral body and lying about 1 cm. from it. The bodies of the verte- brae and the intervertebral disks ap- peared entirely normal. The swelling in the lumbar region was an abscess which was opened and drained. The transverse process was found lying free in the ab- scess cavity and was removed. The ap- pearance of the pus in the abscess cav- ity was typically tuberculous. After the removal of the bone fragment and the evacuation of the abscess the leg pains ceased. A sinus opened in about three weeks which drained profusely. Later the patient began to lose weight and developed signs of a generalized miliary tuberculosis which was confirmed at the necropsy. Cause of Low Back Pain. Thirty-seven of the forty patients whose histories are reviewed by O'Fer- rall designated the lumbosacral joint or 324 SOUTHERN MEDICINE AND SURGERY the lumbosacral angles as the point of pain and in each instance tenderness existed at this point or points. Two designated the left hip and thigh and leg as the site of pain, which was prob- ably referred pain due to pressure of the lumbosacral cord from swelling of the lumbosacral ligaments. One patient referred his pain to the sacrum. Exam- ination revealed that spasm of the spinal muscles existed in some decided form, varying from slight restriction of the spinal motions to complete rigidity, in- cluding also so-called "sciatic scoliosis," in thirty cases. Inspection of the teeth showed that infective foci existed in the form of necrotic teeth, crowns and fill- ings (potential infectious foci) in eigh- teen cases. Five cases showed infected tonsils or nose; seventeen were nega- tive for pathology and eighteen showed no record had been made of an exami- nation of the nose and throat. The treatment given consisted mainly in clearing up infectious foci, administer- ing mixed treatment for those having a positive Wassermann reaction or who were otherwise suspected of having syphilis, and in giving occasional doses of acetylsalicylic acid and cincophen. In many cases no other treatment was required than fixation of the spine. O'Ferrall believes that too much de- pendence is put on the roentgen ray as an aid to diagnosis. Hospital and Sanatorium John Q. Myers, M. D., Dept. Editor North Carolina Hospitals. SANATORIUMS AND CHARI- TABLE INSTITUTIONS. Asheboro Memorial Hospital — 18 beds. Asheville Appalachian Hall — 25 beds. Asheville Mission Hospital — 85 beds. Fairview Cottagie Sanitarium — 30 beds. Highland Hospital — 75 beds. Meriwether Hospital and Training School — 75 beds. St. Joseph's Sanatorium — 50 beds. Winyah Sanatorium — 125 beds. Barium Springs Presbyterian Orpihans' Home — 143 beds. Bayboro Pamlico County Home — 12 beds. Biltmore Clarence Barker Memorial Hospital and Dispensary — 45 beds. Swananoa Hill Sanitarium — 27 beds. United States Public Health Service Hospital No. 45—350 beds. Black Mountain Cragmont Sanatorium — 50 beds. Fellowship Sanatorium of the Royal League — 30 beds. Burlington Rainey Hospital — 25 beds. Caroleen Caroleen Hospital — 20 beds. Castle Hayne '< New Hanover County Home. Charlotte Alexander Home — 25 beds. Florence Crittenton Industrial Home —12 beds. Good Samaritan Hospital — 23 beds. Mercy General Hospital — 50 beds. New Charlotte Sanatorium — 75 beds. Presbyterian Hospital — 100 beds. St. Peter's Hospital — 60 beds. Thompson Orphanage — 58 beds. Tranquil Park Sanitarium — 25 beds. Davidson Davidson College Infirmary — 17 beds. Dobson Surry County Home — 75 beds. Durham Lincoln Hospital — 50 beds. Fayetteville Cumberland County Home — 30 beds. Cumberland General Hospital — 20 beds. Highsmith Hospital — 75 beds. Franklin Lyle's Hospital — 10 beds. Gastonia City Hospital— 33 beds. Gaston County Sanatorium — 30 beds. Goldsboro Goldsboro Hospital — 40 beds. Magnolia Grove Hospital — 10 beds. Odd Fellows' Orphans' Home — 10 beds. Spicer's Sanatorium— 25 beds. June, 1922 EDITORIAL 825 Grenesboro Glenwood Park Sanitarium— 35 beds. Reaves Eye, Ear, Nose and Throat Infirmary — 22 beds. Rest Cottage No. 3—15 beds. St. Leo's Hospital— 100 beds. Wesley Long Hospital — 35 beds. Williams Private Sanitarium — 16 beds. Hamlet Hamlet Hospital — 40 beds. Moncure Hospital — 10 beds. Henderson Sarah Elizabeth Hospital— 25 beds. Hendersonville Dixon Health Resort— 30 beds. Edgemont Sanatorium — 25 beds. Patton Memorial Hospital — 26 beds. Hickory Richard Baker Hospital — 20 beds. High Point Guilford General Hospital— 36 beds. High Point Hospital — 40 beds. Jackson County Alms House Hospital — 25 beds. Kinston « County Home for Lenoir County — 20 beds. Parrott Memorial Hospital — 40 beds. Lincolnton Lincoln Hospital — 25 beds. Lumberton Thompson Hospital — 25 beds. Monroe Quality Hill Sanatorium — 10 beds. The Union County Home — 50 beds. Morehead City Morehead City Hospital — 35 beds. Morganton Broadoaks Sanatorium — 50 beds. Grace Hospital — 30 beds. Mt. Airy Martin Memorial Hospital — 35 beds. Newbern Fairview Newbern Hospital — 20 beds. St. Luke's Hospital — 40 beds. Oteen U. S. Public Health Service Hospital —1,100 beds. Raleigh Mary Elizabeth Hospital— 32 beds. Methodist Orphanage — 75 beds. Rex Hospital — 85 beds. St. Agnes' Hospital— 75 beds, Wake County Home. Roanoke Rapids Roanoke Rapids Hospital — 45 beds. Rockingham Richmond County Home — 40 beds. Rocky Mount Atlantic Coast Line Railroad Hospital —35 beds. Pak View Hospital— 60 beds. •Rocky Mount Sanitarium — 40 beds. Rutherfordton Rutherfordton Hospital — 50 beds. Salisbury Whitehead Stokes Sanatorium — 58 beds. Sanfortf Central Carolina Hospital— 22 beds. Southern Pines James McConnell Hospital — 20 beds. Statesville Carpenter-Davis Hospital — 25 beds. Long's Sanatorium — 50 beds. Tarboro Edgecomb General Hospital — 50 beds. Thomasville Thomasville Baptist Orphanage In- firmary— 40 beds. Wadesboro Anson Sanatorium — 20 beds. Wake Forest Wake Forest College Hospital — 12 beds. Washington S. R. Fowle Memorial Hospital — 12 beds. Washington Hospital — 35 beds. Waynesville Waynesville Hospital, Inc. — 25 beds. West Durham Watts' Hospital— 100 beds. , White Rock Laurel Hospital — 14 beds. Wilmington James Walker Memorial Hospital — 225 beds. Red Cross Hospital for Tuberculosis —30 beds. Wilson Carolina General Hospital — 45 beds. Moore-Herring Hospital, Inc. — 35 beds. Wilson Hospital and Tubercular Home (Col.)— 28 beds. Winston-Salem City Memorial Hospital — 85 beds. 326 SOUTHERN MEDICINE AND SURGERY June, 1922 Forsyth County Tuberculsos Hospital —30 beds. Lawrence Hospital — 20 beds. Public Health Nurse as a Rule Social Worker. Irene Brown, the youngest of nine- teen children, was the spoiled and petted belle of her street in a southern city. At the age of eighteen she was mar-, ried to a railroad engineer and lived happily and prosperously for nine years, when a railroad wreck interrupted this happiness and left Irene a helpless widow. When Miss Mason, a public health nurse, found this widow and her family they were living in a five room house in a rural center, having moved there because "rent was cheap." The family consisted of Irene Brown, the mother; Ruth Brown, oldest daughter, age 17; Henry Brown, only son, age 13; Mary Jane Brown, baby girl, age 12; and Miss Dowdy, age 73, sister to Irene and aunt to the children. When Miss Mason, the nurse, visited the neighborhood school one day, she noticed that Mary Jane (the baby girl) did not jump and play with the other children. Turning to her files she found this childs name among the num- ber, whose records she had laid aside, marked "undernourished, visit at once." Calling at the home, she found only the aunt, "Miss- Dowdy," at home, and she told so many conflicting stories that Miss Mason was regretting this seeming waste of time, but regretted more that no other members of the family were there, because it was imperative that since Mary Jane was 20 pounds too light, something must be done at once. Suddenly the older daughter, Ruth, appeared (she had been there all the time) and with scorn and defiance de- manded "what are you doing here, — to see if I am working?" Miss Mason gladly stated her business and just then a neighbor called Miss Dowdy. Ruth feeling she had met a friend, accepted the confidence offered, completely broke down and sobbed out a miserable story of immorality, begin- ning at the age of thirteen with a mar- ried man. She did not know at first that he was married, and her mother blissfully happy in the assumption that "my child can do no wrong," did not make it her business to ask questions or use her much-neglected powers of observation. Ruth stated that night after night she had cried herself to sleep saying over and over, "Why don't some of these ladies come and get me." meaning welfare workers.) The whole story of the family's grad- ual decline since there had been no male support was sobbed out by Ruth, who had been working in a candy factory, but lost her job — was fired, by the su- perintendent because his son was paying "attention" to her. The blind confidence of the mother was so complete that no questions were ever asked Ruth — her fine raiment and late hours seemed to give her mother no concern. It was almost impossible to find out the net income of the family, for all the adults were professional liars. Many times the truth would have served their purpose much better than some of the statements they tried to get away with. Upon calling at the asociated chari- ties in the nearby city, and church socie- ties it was found that at least six or- ganizations were interested in this family. Miss Mason went to work. Her first step was to make a personal friend of Ruth, while she directed her attention to the 20 lbs. undernourished Mary Jane. She found the family diet con- sisted of all sorts of stuff but mostly innocent of calories and vitamines. Mary Jane's breakfast, usually, was soggy biscuit and black coffee, for lunch crackers or bought cookies from the grocery store, and for supper fried meat, more poor bread and block coflfee, with sour kraut added for a delicacy now and then. The Parent Teachers Association fur- nished milk at the school free for those June, 1922 EDITORIAL 327 who had no money and this proved a Aunt "Miss Dowdy" at 73 washed Godsend to Mary Jane, but the problem enough curtains to earn a few pennies, of her home food would not be solved, but was never cured of lying. That and Miss Mason proceeded to employ seemed incurable, drastic measures to gain her point. Irene was terribly afraid of the law. Miss Mason had ordered Ruth to the venereal clinic and met such stubborn resistance, that it was necessary to call an officer of the law to enforce the re- quest, so that when she found nothing could be done in the dietetic line to im- prove the health of these children, (Henry also was much underweight), liniversity Extension Post-Graduate Medical Course. The University is making it possible again this year for doctors in North Carolina to get a real genuine post- she hinted at the possibility of needing graduate course of instruction without the services of this same officer again, leaving home and without any serious and explained that if Irene failed to interference with their daily work, make a good mother there were institu- Two circuits have been arranged to tions where neglected children might be ^over a period of three months, with six cared for. towns or centers in each circuit so that Frightened at this, Irene began to the instructor can get from each class work but she also began to beg. After to the next over night— that is one day Miss Mason's report, the Associated each week at each place, a total of 12 Charities offered to pay Irene a stated lectures and clinics. sum each month for the support of her This year's course will cover general family and the church offered to help medicine with a lecture followed by with the rent provided the family obey- clinical instruction ed instructions and did not go a begging elsewhere. Every Monday Miss Mason sent home by Mary Jane a menu for the week, and ordered from the grocery store the needed supplies. This was an uphill program at first for Irene had to be taught to cook and to learn calories, vitamines, hygiene and sanitation. Summary at End of Eight Months. Mary Jane gained within two pounds school closed. Last year the work covered pediatrics and proved most vluable. A certificate will be given showing at- tendance and work done, and the course is so planned that it will be really as valuable as if taken in some one of the larger centers. Henry, who hadn't been able to keep a job when he got one, because every day or so a sore throat would keep him out, was operated for tonsils and ade- noids and broken from the tobacco habit. Ruth's examination at the clinic proved negative and she married an Southern Pediatric Seminar. The Southern Pediatric Seminar which proved so valuable and helpful in weight and was last year will be held again this year at of normal when Saluda and Black Mountain for two weeks from July 31 to Aug. 12, inclu- sive. Here pediatricians from everywhere meet in social and informal intercourse and combining recreation with post graduate study make of this a most pleasant and helpful event. The expense is insignificant but the benefit tremendous. There is abundance auto dealer, though he first had to get ^f ^ji^i.^i material and the teaching ^ "^^o^ce. ^^^ ^gg^^ ^^^ pjgj^^y ^f ^ij^g ig allowed Irene, happy in the knowledge of do- for recreation in the mountains and ing her duty,— if supervised— tried to most happy social intercourse with con- carry out the program outlined. gonial friends. 328 , SOUTHERN MEDICINE AND SURGERY June, 1922 Dr. Lesesne Smith of Spartanburg, S. further foetal activity, the doctor could C, will answer your correspondence. get no heart sounds and death of the foteus was evident. The next day she Invalids Home. felt much better and in two or three Miss Gladys Posey of Winston-Salem, days the nausea had disappeared, there is to be commended for her peristence was no more albumin in the urine and and success in conducting a genuine the edema was subsiding. At the end home for elderly ladies. Circumstances of one week she delivered herself spon- often make it impossible for some to taneously of dead twins. The placenta enjoy ideal home surroundings and was still alive and moderately adherant especially so when infirmities of age or but was delivered without great diffi- disease requires unusual care and atten- culty. Upon examination it was found tion. Miss Posey calls her place a Home that there had been a hemorrhage with- and not a Hospital, and her greatest in the placental tissue between the two ambition is that she may have a house chords, which had blocked the circula- full of elderly ladies, each of whom will tion in both chords with the resultant truthfully feel that she has indeed found death of both babies, but no other path- a real home, with all home comforts ology was found either in the placenta and considerations. or the babies. Even, though possible, yet it often The evidence in this case indicates does not suit to live with relatives, and conclusively that the toxemia was sole- for such Miss Posey has provided the ly caused by the metabolic waste from solution. the living, growing babies, and the The customary institutional isolation moment the babies died the cause of the does not exist here, but each member toxemia was removed and the symptoms of this family may have her relatives subsided. The expulsion was accom- or friends visit her any afternoon as plished before decomposition toxins were freely as if she were in her own private formed to be observed and the recovery home alone. ^^s absolutely free from any post par- The rates are very reasonable too, so ^""^ symptoms, that one may live here as cheaply, per- This case is valuable in that it pre- haps more, than elsewhere. sented unusual opporufnities for demon- strating that at least sometimes, as in MECKLENBURG COUNTY. this case, toxic symptoms are not ma- ternal nor placental but solely the re- The Meckleburg County Society g^its of absorption of the toxic meta- meeting in regular semi-monthly ses- ^olic waste of the living child, sion June 6, enjoyed a full attendance ^he papers for the evening were pre- and a very interesting program. gented by Dr. Claude Squires and Dr. J. Under the heading of case reports p Matheson Dr. Oren Moore reported a case of ' ^^ .^^^ ^^^ "Gonorrhea Toxemia of pregnacy that is very im- i^ Children." Several cases were report- portant as showing the possible source ^^ ^^ .^^ infections in very young children, both males and females. of at least some toxemias. This woman, 39 years old, with her ^ ,, , ,. , ^ ,, first pregnancy, after nine years of mar- ^ ^r. Matheson discussed very fully ried life, very early began the tyoical Otitis Media and its related conditions. clinical symptoms and followed a more or less typical course of the more severe Dr. Preston B. Loftin, Beaufort, N. type. Many times, and much of the C, died May 10, 1922. He was about time, it seemed very advisable to inter- 60 years of age, and was graduated and rupt gestation, but because of her great licensed in North Carolina in 1888. He desire for motherood she was willing to was a native of Wayne County, but had take chances and the doctor did his best, been living in Beaufort for a number of At seven months the mother noticed no years. EDITORIAL 329 Dr. Geo. M. Bell, Wakefield, N. C, died May 18, 1922. Dr. Bell was 66 years old, a native of Franklin County, educated in Baltimore, and one of the most public spirited cit- izens of his county. He donated the site, consisting of 10 acres, for the Wakefield High School. Although off'ered many places of honor in public life he refused them all until he was called to serve on the Board of Education and feeling that here was a duty and a privilege he accepted. One of his last benevolent acts was a con- tribution of $500.00 to the Zebulon Bap- tist church. He left a widow, five sons and one daughter: Dr. Carl Bell, Raleigh; Earle Bell, druggist, Zebulon ; Dr. Victor Bell, dentist, Raleigh ; Dr. Eric Bell, Wilson ; Berdon Bell, Wakefield, and Mrs. Lorria Bell Broughton, wife of Dr. N. B. Broughton, Raleigh. New Community Hospital A state charter has been granted to the Drayton Hospital Or- ganization for the new community hospital which will be erected at Drayton, N. C, for which the people of that city will pay. Dr. R. LIcyd Williams, Norfolk, Va., has been elected to fill the unexpired term of Dr. J. J. Miller, deceased, as councilor of the Medical Society of Virginia. Dr. Percy Harris, Scottsville, Va., has been appointed city physician of Lynchburg, to suc- ceed Dr. Gilbert Crank. Dr. Benjamin Blantcn Dutton, Jr., Winches- ter. Va.. was married to Miss Anne Lougheed Carson, of Riverton, Va., April 19. Dr. Chas. H. Barron, Rocky Mount, N. C, died March 17, 1922, at the age of 82. Dr. Barron practiced medicine in Edgecomb County for almost 50 years. He was a Confederate veteran, having served throughout the war. Dr. Robert Gamble Cabell, Jr., Richmond, Va : :\Iedical College of Virginia, Richmond Va , 1870; for fourteen years superintendent of the City Home Hospital; Civil War Ve'- eran; also a druggist; died suddenly. May 7, aged 74. at the Stuart Circle Hospital, from heart disease. Dr. Edward Steptoe King, Sharpsburg, N. C; University of Maryland School of Medicine, Raltimcre, 1889; died April 11, aged 59, at Statesville, from cerebral hemorrhage. Dr. Earl Paul Knotts, Orangeburg, S C, was married to Miss Marjorle Todd of Denton, Md., May 3rd. Dr. K. P. Battle, Raleigh, N. C, died March 23, 1922, at the Chestnut Hill Hospital in Philadelphia, after a linger- ing illness of seven months. Dr. Battle was born March 9, 1859, in Raleigh, graduated from the University of N. C. in 1879. He also received an Md. degree from Belleveue Hospital Medical College in 1882, and the follow- ing year was spent as interne in the Charity Hospital on Blackwell's Island. After this he was in 1884-1885 in the U. S. Marine Hospital service, and then he spent a year, 1886, in European study, particularly in London in special preparation for work in eye, ear, nose and throat. He returned to Raleigh and establish- ed his practice in 1887 and had been constantly, since that date, one of the state's best citizens and doctors. A true example of the best type of honest, wise and useful gentlemen. Dr. Richard K. Allison and Miss Susan Fitz- simmons. both of Columbia. S. C, were mar- ried May 1st. Hospital News — Bids were opened May 10 for the construction of the new $125,000 build- ing for the Lincoln Hospital, Durham. Plans have been completed for a new hos- pital to be established at Greer. The Asheville Normal School is remodeling a building for use as a hospital at a cost of $10,000. Society Elections. The Darlington County Medical Society elected Dr. Alfred D. Gregg, president, and Dr. Julian T. Goggeshall, secretary. At the annual meeting of the Allendale County Medical Society Dr. John E. Warnock was elected president and Dr. G. W. Loadholt, secretary-treasurer. At a meeting of the Oconee County Medi- cal Society, held in Seneca recently, Dr. Wal- liam C. Marett was elected president and Dr. Edgar A. Hines, secretary-treasurer. At the first annual meeting of the South Carolina Padlatrlc Society, in April, Dr. Rich- 330 SOUTHERN MEDICINE AND SURGERY June, 1922 ard M. Pollitzer, Charleston, was elected pres- ident and Dr. E. A. Hines, secretary. Dr. Wm. P. Honton, N. Wilkesboro, N. C, Baltimore Medical College, 1892; member of the Medical Society of the State of North Car- alina; d cd May 6, aged 55. Dr. Wiley H. Young, Clinton, S. C, Atlanta Medical College, Atlanta, Ga . 1887; died May 13, aged 63, from cerebral hemorrhage. Dr. Joseph Eugene Good, New Market, Va., Jefferson Medical College, Philadelphia, 1884; died May 7, aged 60, from meningitis Appropriations for Health Campaign. — The board of county commissioners at a meeting in Raleigh, May first, adopted a health budget for the ensuing year which carries $38,838 for health work and $6,850 for mosquito control. The county government will pay one-half of the mosquito control appropriation and the city the other half. The city will also pay 75 per cent, of the health budget. Dr. Hugh M. Taylor, of Richmond, Virginia, died at his home in that city on May 30,' 1922. Dr. Taylor had been in failing health for more than a year, and his death was not a surprise. He was 66 years old. Dr. Taylor was a graduate of the Medical College of Virginia, and he had feen a mem- ber of the faculty of that institution as well as of the University College of Medicine. For a generation he was one of the outstanding Furgeons of the South, and the news of his death will bring sorrow to his former pupils, his old patients, and his acquaintances. Rear-Admiral Edward R. Stitt. Surgeon- Gen- eral of the United States Navy, addressed by invitation the Richmond Academy of Medi- cine & Surgery on Mav 9. Dr. Stitt spoke on "Food-Deficiency and Disease", and his talk was most enlightening and helpful. Dr. Gar- nett Nelson at the same meeting reported a case of multiple septic serositis. After the meeting the Academy gave a supper at the Commonwealth Club in honor of the Surgeon- General. During his stay in Richmond the Surgeon-General was the guest of Lieut. T. O. Summers. M. C, U. S. N., at the Country Club of Virginia. Dr. Stitt is a native of Charlotte. Dr. Paul V. Anderson, with his class in Psychiatry in the Medical College of Virginia, were recently the all day guests of Dr. W. F. Drewry. Superintendent of the Central State Hospital Petersburg, Virginia. Dr. Drewry rlaced himself, his staff, and the institution at the disposal of the class. A splendid clinic was held, and the entire class were Dr. Drewry's ^-''ests at luncheon. Psychiatric clinics in the nearby State Hospitals are a forward step in the teaching of mental medi- cine in the Medical College of Virginia. Dr. Beverley R. Tucker, of Richmond, has just returned from Quebec, where he read a paper before the American Psychiatric Asso- ciation. The Graduation Exercises of the Medical College of Virginai were held in the Strand Theatre in Richmond on Tuesday evening, May 30. Dr. J. M. T. Finney, of Baltimore, spoke to the graduating class. The graduates in medicine numbered 27, of whom two are women; the graduates in dentistry 18, 3 of whom are women; the graduates in pharmacy 20; and 11 nurses — from the Memorial Hos- pital— also received certificates of graduation. Dr. E. A. Hall of Iredell County, North Car- olina, visited his son. Dr. James K. Hall, in Richmond, during the commencement of the Medical College of Virginia. Dr. E. A. Hall was a member of the class of 1868, and he is one of the oldest living alumni of that college. In the street parade of the college during commencement — com- posed of faculty, alumni, and graduating rlat>:es. Doctor Hall occur^ied the seat of honor in the float, which was a replica of the old building of the Medical College of Virginia. Dr. K. D. Graves and Dr .W. B. Porter, of Roanoke, were both recent visitors in Rich- mond. The Meeting of the Richmond Dental So- ciety, held in the Medical College of Virginia on June 1. was addressed by invitation by lour physicians of Richmond. Dr. Emory Hill spoke on dentistry from the viewpoint of the ophthalmologist; Dr. James K. Hall viewed the resposibility of the dentist from the viewpoint of the neurologist; Dr. Michaux talked about the value of co-operative effort between sur- geon and dentist; and Dr. Warren T. Vaughan viewed dentistry from his work as an internist Dr. Paul V. Anderson, of Richmond, attend- ed the twenty-fifth anniversary of his gradu- ation from Trinity College at the recent com- mencement of that institution. North Carolina. The nurses examining board at its recent examination granted license to 78 applicants to practice nursing in North Carolina. The successful applicants and the school from which graduated are as fol- lows: Appalachian Hall Asheville — Annie Laurie HarriFon. Tessie Mae Smith. Army School of Nursing, Walter Reed Hospit'il —Ethel C. Cathey. Eak"r Sanatorium, Charleston S. C— Annie O. West. Carolina General, Wilson— Mrs. Mary Thigpen Strickland. June, 1922 EDITORIAL 331 Central Carolina, Sanford — Fanny L'j.iluon Dixon. Children s Hospital, Washington, D. C— Sarah Adelia Ker.drick. Charlc.te Sanaior.ui;'.— Ruth Croshy, LiUir Mae Morris, Caroline A. McQueen, Mary Eliza- beth Rodwell, Amela Grace Stephenson. Mary Lou Wagner. City Hospital, Fai.nicnt, W. Va. — Mrs. Henry Sloan. City Memorial Hospital, Winston-Salm, N. C. — Flora Octavia Keiger, Mary W. .Murphy, Mamie Gertrude Thomas. Clarence Barker Memorial, Baltimore -Edith Cotterill, Mamie Louise Shroat, Sara Tay- lor. Dix Hill Hospital, Raleigh — Mrs. Henrietta Smith Shuffler. Columbia Hospital, Washington D. C. — Grace Elizabeth Allen. Cumberland General, Fayetteville — All'e Ta- tum. Essex County, N. Y.— Esther C, Haller. Florence Infirmary, Florence. S. C — Goldie E. McCoy, Laura Vermelle Owen, Katharine Smith. Friend s Hosptal, Frankfort, Pa. — Mrs. Klsie G. Guffy. Grace Hospital, Morganton — Vida Gordon But. Highland Hospital, Asheville — Eleanor Hind- man Nesbitt. High Point Hospital — Annie Lee Bergman, Rosa Cheek, Fay Horney, Nellie Louise Muse. Highsmith, Fayetteville — Gladys McDonald Flossie Lipe Smith. James Walker Memorial, Wilmington — Myrtle Sanders. Knoxville General Knoxville, Tenn.— Mrs Eliz- abeth G. Baldwin. Lincoln Hospital, Lincolnton — Neta S. Daal, Sarah Y. Miller. Long's Sanatorium, Statesville — Ruby Holt- Houser. Mary Elizabeth, Raleigh — Rosa Edith Thayer. Mercy General, Charlotte— Ina H. Phillips. Sa- die McDonald. Metropolitan Hospital, New York — Ursula Potts Missouri Baptist Hospital. St. Loui^ — Kathryn Duguid. Moore-Herring, Wilson— Cora Lee Green, My- tle Aileen McNabb. Mt. Vernon Hospital, Mt. Vernon, N. \. — Myr- tle Smith. Parrott Memorial. Kinston— Pearl Parker. Presbyterian. Charlotte — Claudia Mae Baker. Fay Miller, Janet Monroe, Ivan Kathleen Rudisill, Kate Simpson. Pryor Hospital. Chester, S. C— Nancy Allena Mabry, Leona Smith Alma A. West, Re-c Hospital. Raleigh— Elizabeth Sue Grump- ier, Virginia Grace Hunt. Beulah Geneva Jurney, Marie Johnson McKenzie, Gladys Lee Taylor, Esmaralda Walton, Sarah E^hel Williams. S. C. Baptist Hospital, Columbia, S. C— Jane C. Thorpe. St. Agnes, Raleigh — Madeline Douglas Gilmer. St. James Mercy Hospital, New York — Mary Harlon Curtis. St. Leo's, Greensboro — Mary V. Durham. St. I ukp's. Now Born — Lalla Fentress, E !na E. McKee, Tini McKee. St. Peter's, Charlotte — Bertha Howard, Anna- bel Robinson. Watts, West Durham— Lillie Marie Brock, Eula Gertrude Reeves, Callie Frances Wilson. Whitehead-Stokes, Salisbury — Mary Lily Os- born. Reciprocity Certificates. Certificates of reciprocity or recognition were granted to nurses registered in other states as follows: Miss Rosa H. Law and Mrs. A. H. Suker, of Florida; Mrs. Margaret Estelle Getz, Georgia; Misses Florence Aileen Lightner and Sara Mul- berry, Kentucky; Misses Gertrude Dickhut and Regina Klingman, Louisiana; Misses Myrtle Mae Adams, Harriet Anderson and Mildred Riese, Massachusetts; Miss Mabel Brown, Ok- lahoma; Misses Olive Goodman, Ethel Edith Holmes. Selma Poetz, Lois Gates and Annie Elizabeth Miller (col.), Pennsylvania; Mi^s Elizabeth M. Kelty, Vermont; Misses Garfield Leech. Ruth Council and Annie Keith Brown, Virginia; Miss Lillie Lowe, Arkansas. Publications Received Practical Infant Feeding.— By Lewis Webb Hill, M. D., Junior Assistant Physician to the Chil- dren's Hospital, Houston; Assistant in Pediat- rics, Harvard Medical School. Octavo of 483 pages, illustrated. Philadelphia and London: W. B. Saunders Company, 1922. Cloth, $5.00 net. This is a valuable book. All the way through one is impressed with the fact that the author does not lose sight of his avowed purpose in the beginning, viz.. to help the practitioner not only to treat but to understand feeding cases as they occur in his daily practice. He assumes an obvious fact that no one can successfully treat babies until he has considerable knowl- edge of the chemistry of metabolism in normal and abnormal babies. There seems to be throughout a happy com- mon sense combination of science and prac- tice and also, instead of blindly following the teachings of any one school there is a happy amalgamation of the best points taught in this country and abroad. Surgical and Mechanical Treatment of Periphe- ral Nerves— By Byron Stookey, M. D., Asso- ciate in Neurology, Columbia University; As- sistant Professor of Neurosurgery. New York Post-Graduate Medical School and Hospital. With a chapter on Nerve Degeneration and Regeneration, by G. Carl Huber. M. D., Pro- fessor of Anatomy, University of Michigan. Octavo volume of 475 pages with 217 illus- trations, 8 in colors and 20 charts. Philadel- phia and London: W. B. Saunders Company, 1922. Cloth $10.00 net. The aim of this book is to give principles and methods whose foundations are laid in em- bryology, anatomy and physiology as well as in ex-;'^rimentPl work and in clinicil practice, and the author advocates the use of only such procedures as have, by such criteria, been flhown to him to be of value. 332 SOUTHERN MEDICINE AND SURGERY June, 1922 Table of Contents for June, 1922 Original Communications. Reflections on Medical Ethics, by Davis Furman M.D. 277 Therapeutic Impressions, by Ivan P. Bat- tle, M.D. 288 Points of Differentiation Between Kidney and Intraabdominal Lesions, by A. J. Crowell, M.D. 292 Osteomalacia — Report of Case, by Charles P. Mangum, M.D 295 Some Further Observations and Reports of Cases in the Instillation Treatment of Enuresis in Childhood, by Wm. R. Bar- ron, M.D. 296 Some Observations on Endoscopy. Report of Four Different Cases, bv C. N. Peeler, M.D., and C. C. Phillips, M.D 299 Stalking the Streptococcus, by Edgar M. Long, M.D. 303 The Problem of a Clinical Medical School in North Carolina, by I. H. Manning, M.D. 311 Editorials. A Finished Medical School for N. C 316 Tossat Gasometer Installed at State Sana- torium 316 Criminality 317 Department Editors. Surgery, A. E. Baker, M.D 319 Gynecology and Obstetrics, Robt. E. Sei- bels. M.D. 320 Urology. A. J. Crowell, M.D 321 Mental and Nervous, Jas. K. Hall, M.D._- 322 Orthopaedics, Alonzo Myers, M.D 323 Hospital and Sanatorium, John Q. Myers, M.D. 324 Nursing 326 News Items 327 Publications Received 331 In discussing the subject of nerve surgery he stressed the importance of the microscopic as well as the gross anatomy, on the ground that the more successful nerve surgery is the nearer it must approach what may be termed histological surgery. Also, at times, stress l.as been placed on the comparative anatomy and embryology. Important measures, other than surgical, have also been emphasized. Throughout the work the principles advocat- ed and the teachings of Sir Robert Jones are manifest. The chapter on "Nerve Degeneration and Re- generation"' was written by Dr. G. Carl Huber, of whom we have heard so much since as long ago as 1895. Practical Organotherapy — The Internal Secre- tions in General Practice. By Henry R. nar- rower, M. D. Third Edition, rewritten and enlarged. Octavo, 416 pp., cloth, $1.00 net, 1922. The Harrower Laboratory, Box 68, Glendale, Calif. Since the days of Brown Sequard, the "spon- sor of scientific organo-therapy," the adminis- tration of preparations of animal organs has been used and discarded and used again. It ii indeed a study of perennial interest and at no time has this subject attained so great and infrpa«ing a vo9:ue as at present. Such medication has some quite marvelous results to i^s credit and inevitably many en- thusiasts bT"e sprung up to champion its cause, wh'le on the other hand there are many who condemn quite properly, over-zealous entheuslasts. The unprejudiced juror is the one who will without bias or malice weigh the evidence in the cose and sift out the true from the false. Management of the Sick Infant — By Langley Porter, B.S., M.D., M.R.C.S.. L.R.C P., and William E. Carter. M D., San Francisco, Cal.; 654 pages, 54 illustrations. Price, $7.50. C. V. Mosby Company, St. Louis, Mo. The avowed object of the authors of this work is to deal exclusively with the peculiari ties of disease as it occurs in infants — to codify the things that have proven helpful in dealing with sick babies and present them in readable and logical form. Especially to be noted in this book is the sec- tion devoted to practical methods of treatment with illustrations and explanations many of the difficulties of treating and handling sick babies have been made simple and easy. In these descriptions little is taken for granted or left to the imagination of the reader but clearly explained. The book throughout is an innovation in its style and its planning. FOR SALE. One Horley M. Jones basal metabol- ism apparatus in perfect condition ; also full oxygen tanks, charcoal, and sodium hydrate for use with same. Reason for selling: installing Tossat type of apparatus. SUPERINTENDENT, Sanatorium, N. C. Southern Medicine and Surgery Vol. LXXXIV CHARLOTTE, N. C, JULY, 1922 No. 7 DIAGNOSIS IN NON-VALVULAR manifestations of syphilis or malaria CARDIAC DISORDERS* etiology is of paramount importance in T. T, T. T v T. ,, T. . ..r A„ , » T^ trcatmBnt, structural and functional al- By R. F. Lembach, M.D.. and Wm. Allan. M.D., derations assuming a secondary role. We Charlotte, N. C. _ , j.-l. j^ .^ . j^-, .i may observe therefore that the three The cardiac disorders which we are elements of a perfect and adequate diag- going to consider rather discursively to- nosis ; viz., structural change, functional day under the above heading are linked disturbance and etiology do not, in the together by one common quality only present state of our knowledge of dis- and that is that their identity depends ease processes, always stand in the same solely on a characteristic disturbance of relative relationship to treatment, function, and that structural changes of ^o argument we think will be forth- a constant nature are not predictable eoming in this group of clinical men if with any defree of certamty, while their ,,.^ g^^te that in cardiac disorders, the etiology is unknown except in very gen- functional element in diagnosis presents eral terms. Indeed the terms which are jt^glf in its maximum importance. Struc- employed in their diagnosis define dis- tural changes in the heart valves or turbed function and not pathologic an- musculature are not amenable to sur- atomy. Yet these cardiac disorders have ggry, nor can we claim that they yield to become of vast importance clinically, in medicinal or hygienic measures "to any that they are brought forward as major significant degree, save only in syphilitic complaints in a large gi'oup of cardiac affections of the heart. We may apply patients, and that the recognition of the specific therapy based on etiologv, in specific type of disturbance is productive syphilis of the heart, and in rheumatic often of a valid prognosis, and some- endocarditis and gonorrhoeal endocar- times of an almost specific remedial ^itis etiology assumes a significant role therapy. ^^ ^yie prevention of further metastasis We may for a moment pause to con- from a remote focus of infection. Car- sider that an adequate and thorough- diac therapy today, however inadequate going diagnosis should inform us first of that therapy may be, rests most solidly structural pathologic changes, second of on functional values. Ten years ago the nature of the functional disturbance, during that discouraging era of thera- and third of the ultimate cause of the peutic nihilism, a therapy based on func- condition. These three elements of a tion was slightingly referred to as em- perfect diagnosis are not always of equal pirical and symptomatic. Today, thanks importance. To the pathologist and to the intensive researches of the past sanitary statistician, etiology and path- ten years in pathologic physiology, we ologic anatomy are all important, while know that a highly remedial therapy functional disturbance during life is may be constructed on functional values only of passing interest. To the sur- even though the ultimate cause of the geon in the treatment of the tumor or disorder be still hidden from us. Men- gall stone case the anatomic and func- tion of the present day treatment of tional elements are sufficient to deter- diabetes is sufficient to illustrate this mine remedial measures while etiology point. In cardiac disorders we may re- assumes an importance only in a social fer to the quinidine treatment of auricu- and collective sense. In the varying lar flutter and early fibrillation. * R«.,,, i„ , r , .1, „,. c. , ^" the light of these facts may we * Kead in part before the Winston-Salem , ^ j. . • .• . ,. Meeting of the North Carolina Medical Society, 'onger neglect to investigate most pains- April 25-27, 1922. . takingly those functional disorders of 334 SOUTHERN MEDICINE AND SURGERY July, 1922 the heart so often found unassociatecl with valvular disease and yet productive of so much distress on the part of the suffering patient, and so much apprehen- sion on the part of his or her relatives? The cardiac manifestations which we will consider, and consider practically exclusively in their functional and clin- ical relationships are: (1) The Tachy- cardias, (2) Arrhythmias, and (3) Car- diac Syncope. The tachycardias, whether persistent or paroxysmal are in our experience the most frequent of all disorders encoun- tered in clinical work and the causes and types are multiple. A differentiation between various types is sometimes a difficult matter, but this differentiation must be attempted if we would relate cause and effect and relieve these suffer- ers. Sometimes the relief afforded may be nothing more than that of dissolving an apprehension psychosis, while again more material relief may be afforded by carefully chosen measures based largely on functional values. _ Every clinician knows that the subjec- tive discomfort arising from a tachy- cardia bears a very direct ratio in most cases to the degree of ventricular accel- eration, while rapid auricular rate per se give rise to less discomfort. Ven- tricular rates of 160 and over, even though of short duration, rarely pass unnoticed by the patient and are pro- ductive of immediate sensations of weakness where the sensorium is intact. Rates of 130 to 160 give rise to relative feelings of weakness and fatigue when prolonged for hours and days as they sometimes are. Ventricular rates as low as 120, lasting days and weeks continu- ously or recurrently, are, in our experi- ence, almost always associated with a marked fatigability and lowering of the individual's exercise ability. No tachy- cardia, whether high-grade and of brief duration, or low-grade and persistent, should be passed over without a careful study. We do not purpose to discuss at length various types and causes of tachycardia. It is often an exceedingly difficult prob- lem to solve and indeed a problem which recurs again and again in the course of observation, whether the cause of a tachycardia relates to the heart itself or to conditions remote in other organs. It is most satisfactory in our experience to make a primary differentiation between tachycardia of sinus or extra-cardiac origin, and that associated with intra- cardiac disturbance. We use the word "origin" here in a functional sense and W^s^^f&^tmm 1. A tachycardia of 150 per minute of sinus origin, no disturbance with the heart itself. Normal auriculo-ventricular sequence. Isil 2. Auricular Flutter, with 2:1 block. Clin- ically tachycardia. Quinidine Sulphate the remedy of choice today. not an etiological sense. Four types of tachy- cardia are functionally of intra-cardiac origin. These are: (1) So-called paroxy- mal tachycardia, (2) paroxysmal or per- sistent auricular flutter, (3) paroxymal or persistent auricular fibrillation, and .(4)thatrecently described auricular disorder "Coarse Fibrillation." We shall not speak of the nature of the auricular disturb- ance underlying these cardiac disorders or the associated symptoms which may be produced by them. It is sufficient to say that their most obvious and major symptom is that of tachycardia. By their clinical features alone, these four types July. ir22 ORIGINAL COMMUNICATIONS 335 of auricular disturbance, when of par- 150 per minute as a paroxj'smal sinus oxysmal type, are differentiated with condition in one patient, and again a considerable difficulty, if indeed they are ventricular rate of 150 as a manifesta- differentiated at all. On the contrary, tion of impure flutter, a true intra-car- all four types are differentiated with diac auricular disturbance. The impor- much ease from each other and from tance of making a careful study of this sinus tachycardias due to causes lying common complaint of tachycardia is ap- outside the heart, by means of the elec- parent when we consider the therapeutic trocardiograph. This method we have use of a drug in large doses, so potent for employed with the utmost satisfaction good in true auricular disturbances and for the past year. Other means of in- so futile, and sometimes even harmful, vestigation, as for instance the poly- in other varieties of tachycardia as quin- graph, may be used to the same end. idine sulphate, the recently revived use The widespread and increasing use of of which has brought about such aston- instruments of precision in the study of ishing things in cardiac therapy, heart conditions is convincing proof of Arrhythmias— A pulse irregularity, the value of graphic methods, for it is whether associated or not with other only by removing all elements of uncer- manifestations of cardiac disorder, is a tainty that one may proceed to adminis- symptom which commonly presents sub- ter counsel or therapy with any convic- jective as well as objective elements, tion of its rationality. The subjective element not infrequently Having determined by an electrocar- forms the basis of an apprehension psy- diogram or other graphic means, the chosis in patients who accustom them- presence of a normal sequence between selves to counting their own pulse or auricles and ventricles of less than one- who focus their attention on the some- fifth of a second and the existence of times disturbing sensations of thumping normal auricular waves from impulses or prolonged diastoles of various ar- arising at the sino-auricular or Keith- rhythmias. It is entirely safe to say Flack node, we may conclude that the that any cardiac irregularity, whether tachycardia is of sinus type and origin recognized by the patient or not as a and is due to excitative or depressive in- subjective symptom, is deserving of just fluences reaching the heart by way of its that amount of study which will serve to sympathetic or autonomic nerve connec- tions, as the case may be, or again that it may be compensatory to altered venous inflow. After this primary dif- ferentiation has been made, one may proceed with confidence to investigate by means of metabolism estimations and other available diagnostic measures re- moter causes of tachycardia; such as, hyperthyroidism, tuberculosis, etc. We do not mean to imply that causes in 3. Impure flutter. A disorder of cardiac which the cause or nature is frankly ob- "mechanism only recently described Chmcal^^^ ,.;^„„ -4. 4-4. • ju u •i./jx tachycardia of 150 per minute with irregular- VIOUS, as It often is, need be submitted to .^^^^ ^^^ ^j^ ,,,^^1,5 duration. Diagnosis possible graphic study, but where doubt exists or only by electrocardiogram. A normal me- even suspicion of any intra-cardiac dis- chanism restored in 72 hours by quinidine turbance, graphic methods are almost sulphate, indispensable. In general one may say that the extra-cardiac causes of tachy- establish its true nature, no more and cardia rarely ever produce the high ven- no less. If the attending physician gives tricular rate seen in the tachycardias of close observation to the clinical signs either of the four general types of intra- present and audible with the stetho- cardiac disturbance. The border line is scope, a valid judgment may sometimes not clear-cut, however. We have seen, be made. One should always be able to in close sequence, a ventricular rate of recognize the isolated ventricular prema- ^^Mi^W^^'¥^ii4< SOUTHERN MEDICINE AND SURGERY ture beat. Its clinical characteristics are practically unmistakable. Its pre- maturity, the compensatory pause, the weak or perhaps absent radial beat, the double or perhaps single sharp sound in- terrupting the normal sequence, and the presence of a dominant rhythm are con- clusive. Despite the great frequence of this form of cardiac irregularity and its relative insignificance, we have seen re- cently a patient presenting this simple : l.v:. . : .. .....-■ 1 -rm— ' ' ' ' i -4-r- K- ^ ■^ '' ! -^^ — i — 1 i%|i|iii^iipyi/^ii^^ fSfT ^4_.^ Ci..J. -C^ :'Tr ■ ■: J-./ : -.'..^'. ■. „;..^^| 4. Auricular Fibrillation. Pulsus irregu- laris perpecus. Absolute irregrularity. type of irregularity on the verge of aban- doning his means of livelihood for the want of a little reassurance. In one case we have seen unusual complexes of premature beats so com- bined with other ectopic beats as to sup- press almost entirely the dominant rhythm. Auricular fibrillation was the only tenable clinical diagnosis. An elec- trocardiogram rectified our mistake. We may mention as one of the least sig- lar and auricular. There is complete suppression of all cardiac sounds and the pulse wave is totally absent in the ar- teriogram. It may be confused with heart block at times. The familiar sinus irregularity, so common in childhood and in young adults, is rarely ever a matter of con- cern in diagnosis, as when at all pro- nounced its characters are readily rec- ognized. The various forms of organic heart block present a more serious phase of cardiac irregularity and one which should be recognized and identified on ac- count of the bad prognosis which at- tends it. By the ordinary clinical methods of examination a complete block is more readily recognized than the partial or incomplete form or block of the main bundle, for when total disso- ciation between auricle and ventricle has occurred, a slow, dominant rhythm is re- stored and we may find an exceedingly slow and rhythmic pulse. It is in the incomplete form that irregularities are seen. Graphic methods in this type of 5. High-grade irregularity of pulse simu- lating auricular fibrillation clinically. Elec- trocardiographic diagnosis right bundle branch block, delayed conduction over main bundle, irregularity due to ventricular premature beats and ventricular escape interrupting a normal sinus rhythm. Auricles not fibrillating. Diag- nosis only by electrocardiogram. nificant types of irregularity the so- called sino-auricular block, a rather rare type and one quite difficult to identify with certainty without the aid of graphic methods. It is characterized by total cardiac inactivity during a period of one or two full cycle intervals. It can only b3 diagnosed by graphic methods where a tracing shows asystole both ventricu- 6. Ventricular Premature Beats interrupt- ing a normal sinus rhythm. A premature beat follows each normal beat with great regular- ity. Pulse rate 44 to the minute. Symptoms: dizziness and weakness. cardiac irregularity become of greatest importance, for when the underlying myocardial lesion has broken the con- ductivity of the right or left branch of the bundle of His, no clinical measures except the electrocardiogram serve to identify this condition for us. We have had referred to us during the past twelve months six cases of various types of heart block, none of them showing total dissociation. Four show- ed involvement of the main bundle of His and two of the right bundle branch. In July, ir'2: ORIGINAL (COMMUNICATIONS 337 only one case was there an associated valvular lesion, and in this case the block was apparent only as a prolongation of the auricula - ventricular conduction time. In only one case were the clinical signs so unmistakable as to permit a positive diagnosis without the use of graphic methods. Heart block should be suspected by the observant clinician when any of the following conditions are noted. (1) Marked or extreme slowing of the pulse. (2) When dropping out of a cardiac cycle occurs preceded or followed by ventricular quickening. (3) Coupling or tripling of ventricu- lar beats. (4) Reduplication of the first sound, or more rarely reduplication of the sec- ond sound. (5) Apical thrills or rough murmurs confined to mid or early diastole (due to auricular contractions during the dias- tole of the ventricle) . (6) Sudden and exact halving of the ventricular rate. 7. IKarl 1,U., ,^. W-nUicles iv.-.i.oiidinK to alternate auricular beats. Cardiac syncope most often seen in this type of disorder. P — auricles, R ventricles. (7) Murmurs and thrills preceding and following certain beats, but not others. (8) Intensification of the first sound. (9) Rapid pulsation in the neck dur- ing ventricular diastole. (10 Prominent venous pulsation in the neck of intermittent nature, occur- ring when systole of auricles and ven- tricles coincide. By graphic methods, and most pre- cisely by the electrocardiogram, this form of disturbance in the cardiac mechanism, whether simple or associ- ated with disturbances in the auricular mechanism, whether complete or partial, 8. Block of right bundle branch. Diag- nosis possible only by aid of an electrocard- iogram. is clearly brought to light. It is, of course, significant of serious myocardial changes, except in those cases where the block is transitory and secondary to digitalis or drugs of this class or as the result of vagal inhibition arising other- wise. In the cases due to drugs, vagal inhibition may be abolished by atropine and the organic or functional nature of the condition readily established. The third cardiac symptom forming a definite and distinct complaint observed in patients who may manifest no symp- toms of valvular or other cardiac disease is the syncopal attack. Let us say at the outset that much remains to be learned about cardiac syncope. Nearly one hun- dren years have passed since Adams in 1827, and later Stokes in 1846, described cardiac fits in patients with very slow ventricular rate, possibly heart block, to which type of fits their joint names be- came linked. There is not today univer- sal agreement on the exact characteris- tics of the Stokes-Adams syndrome. However, sufficient observations with graphic records have accumulated since the introduction of the polygraph and electrocardiograph to reveal at least cer- tain elements of its mechanism. It has been observed that cardiac syncope may occur in patients presenting either ex- tremely low ventricular rate or ex- tremely high ventricular rate. What- ever their method of production, Lewis states that the immediate disturbance of consciousness is due to cerebral anae- mia. In the first case, where associated with extremely low ventricular rate, the anaemia is due to prolonged cardiac asystole. In the second case, where as- sociated with extremely high ventricular 338 SOUTHERN MEDICINE AND SURGERY July, 1922 rate as in auricular flutter, the cerebral ganic nervous diseases, or the fits of anaemia is the result of a diminished petitmal in epilepsy. It is merely in- cardiac output resulting from imperfect tended to draw attention to suddenly filling during the greatly shortened dias- developing syncopal attacks in patients tole. Lewis states, after examining a who have shown no manifestations of number of published papers, that ven- organic nervous disease, in order that tricular stand-still or asystole lasting a scrupulous study of the heart condition two or three seconds produces little dis- may be made. turbance and that the patient may mere- We have seen in the past year three ly be vaguely aware of the cardiac de- unquestionable cases of cardiac syncope fault ; that stand-still of three to five sec- of recurrent nature. In the case of one, onds produces momentary loss of con- a patient with 2:1 heart block atropine sciousness ; that asystole of twenty sec- has brought considerable benefit. A sec- onds duration usually produces twitch- ond died early in our observation of him. ings or convulsive movements, sighing In a third the condition was apparently respiration, and gradual cyanosis, and due to a momentary anaemia from a se- that recovery is rarely witnessed after quence of extra systoles, one tracing an asystole of ninety to one hundred showing an interval of approximately a twenty seconds. We may perhaps not second and a half without an efficient consider these figures valid for normal ventricular beat. hearts, as published papers dealing with In conclusion, we wish to stress the cases of cardiac failure during opera- fact that in practically no type of disor- tions have shown recovery after even der of the cardiac mechanism, whether 10 minutes or more where cardiac mas- or not associated with valvular disease, sage has been instituted. Cerebral anae- should the exact nature of this disorder mia is perhaps tolerated differently by be left in doubt. Where clinical methods different patients and a fatal termina- establish an accurate functional diagno- tion may be just as likely due to the ^is, as they will do in many cases, cardiac disease itself, as to cerebral graphic methods are indispensable. The anaemia, in the light of the results of irremediable nature of a cardiac disor- cardiac massage ^^^ ^^ "^ warrant for neglecting an ex- Cardiac syncope is, of course, most ^^^ ^"^ painstaking investigation of its common in cases of heart block of high- mature. It is no less a function of the grade in which a momentary increase of Phvsician to administer sane and saga- the block occurs, oft-times it has been "ous counsel m important matters relat- observed with an increase in the auricu- '^^. ^^ ^he conduct of life of a cardiac lar rate, but decrease of the ventricular Patient, than it is to administer well rate. The explanations are too theoret- chosen remedies, ical to be reviewed here. Lewis has shown that a heart block may come on DISORDERS OF THE HEART MECH- suddenly, causing cardiac syncope dis- ANISM* appearing and recurring in a spasmodic manner for some time before the block ^^ '■ ^- ^"^^°^' ^•^•' Charlotte. N. c. becomes permanent. Again it has been The conceptions of heart failure and shown that in complete heart block the role which valvular defects and myo- where the ventricle has been function- cardial degeneration play in its produc- ing efficiently at its own slow rhythm tion have undergone radical revision in that the ventricle may suddenly pass into the past ten years. This has been a momentary condition of asystole with largely due to the investigations inaugu- resulting syncope. In certain types of I'^ted by McKenzie & Lewis and their heart block atropine may furnish some work with instruments of precision— the measure of relief. In complete dissocia- X-ray, Polygraph, and Electrocardio- tion it has little or no influence. graph. Time does not permit a discussion of differential diagnosis between fits of car- ,, * ^f '1J^^^"°''^.^^^ ^^^'^Ti""^ w ^T^'^^^^of ,. . . , ,, . , , .,1 the North Carolina Medical Society, April 25- diac origin and those associated with or- 27, 1922. July, 1022 ORIGINAL COMMUNICATIONS 339 But Lewis has done another work of equal importance. Beginning several years ago, he led the way to the discov- ery of simple tests by which we may recognize most of the important disor- ders of the heart's mechanism. Since graphic methods of study are out of the question for many patients, it is important to become expert in dif- ferentiating these disturbances of mechanism by simple methods that re- quire no complicated apparatus. General Etiology and Pathology. While temporary, mild disturbances are sometimes caused by toxins, by med- icines given injudiciously, or by disease in other organs ; in general, the etiolog- ical and pathological factors back of most of these conditions are rheumatic infection, syphilis, myocardial degenera- tion, or arterio-sclerosis. There may or may not be valvular defects or stenosis. The essential thing is the degree of in- tegrity of the heart muscle and of the conduction system conveying impulses to it. Normally, the impulse begins in the pacemaker, the sino-auricular node sit- uated at the junction of the superior vena cava and the right auricle. It trav- els through the auricular muscular fibres and causes contraction of the auricle. From the auricle, it is transmitted to the auricular ventricular node, and thence, through the branches of the bundle of His to the ventricles. Each auricular systole occurs in regular rhythm at a rate of about 72 to 80 per minute and is followed, similarly, in about .15 second by ventricular contraction. The most common disorders, and the ones that are discussed here are : 1. Sinus Arrythmia. 2. Heart-block. 3. Premature contractions or extra- systoles. 4. Simple paroxysmal tachycardia. 5. Auricular flutter. 6. Auricular fibrillation. 7. Alternation of the heart. /. Siniis Arrythmia. There is a gradual waning and wax- ing of auricular rate which is repeated periodically and which is followed ex- actly by the ventricle. It is found in young adults who show an increased heart rate on deep inspiration and de- creased on expiration, even when there is no increase of respiratory movement. A similar irregularity is found often in young children. It is of vagal origin and is not a serious condition. It is the most frequent condition that brings the moth- er to consult the physician about the ir- regular heart of a child. The radial beats and apex pulsations correspond. These vagal irregularities all disappear when the average pulse rate is increased by exercise, fever, amyl nitrite or atro- pine. They require no treatment and the child's activities should not be re- stricted on account of them. iporlor vena cava SI ?=^-r y A.r,o.ve„.r,..>..ar / RlgM !iurlclr....l.- Rlght ventrklo \- nt.Tlor vcDa cava ^ Ftbers of Purklnje Left ventricle Fig. 2. A diagrammatic representation of the action of a heart affected by sinus arrhythmia. The contractions of auricle and ventricle are represented by the thin and broader black rectangles, A and V respectively. The auricle contracts at the beginning of each cycle, and sends its impulse, indicated by an oblique line, to the ventricle, which responds. The irregularity consists of a waxing and waning of rate, in which auricle and ventricle participate equally. — Lewis. THE CONDUCTION SYSTEM HEART. //. Heart-Block. OF THE This is a condition in which the im- „.„,.,. ^, . ^ , . pulses from the pacemaker fail either bi^. 7 bhowmg the approximate relation ,. ,, j. j. n ^ i .i j. • of the more recently discovered structures to Partially or totally to reach the Ventri- familiar anatomical divisions of the heart, cles and excite the usual rhythmic con- — Smith. traction. In the former event, there is 340 SOUTHERN MEDICINE AND SURGERY July. 1922 partial heart-block ; in the latter, com- plete heart-block. A slight impairment of the conduction tissues uniting auricle with ventricle causes a retardation of response or prolongation of the interval between the auricular and ventricular systole. This is called first degree heart- block. Where the heart-block is higher, the ventricles fail entirely to respond ^.^ ^^ ^ ^.^^^^^^^ ^^ 2:1 heart-block, in to occasional auricular impulses, and ^^^j^j^ ^^le ventricle responds to each second this causes what is called "dropped auricular beat.— Lewis. beats" or second degree heart-block. In a still higher grade, the ventricle ' ' ! ' I I \ Case No. 1. responds to every alternate impulse Several years ago I saw, in a neigh- from the auricle — this is 2:1 heart- boring city, a case of pneumonia to block. Still higher grades are 3:1, and which we decided to give digitalis. Ten 4:1 heart-blocks. When no impulses days later, I was hurriedly summoned to from the auricle reach the ventricle, we come again on account of threatened have complete heart-block. The ventri- heart failure. It was found that the cle then contracts in response to im- pulse which had been beating about 90 pulses originating either in the lower to 100 per minute had suddenly dropped part of the "bundle of His" or in the to 45. Palpation and auscultation over ventricular walls. This results in a the ventricle showed that the ventricular rhythmic slow contraction of 45 to 30 or contractions were also 45. I diagnosed , digitalis accumulation and advised its ^^^' discontinuance. The patient recovered Causes : promptly. This was a case of 2 : 1 heart- Too free use of digitalis may cause block — the ventricles corresponding to what is sometimes called functional every other one of the auricular con- heart-block. It may induce heart-block tractions, in a heart already predisposed to it. Or- jjj Premnture Contraction. ganic heart-block is produced by syph- j^ ^^^ 1^^ ^^^^^ r^^. ihs, rheumatism, arterio-sclerosis, diph- ^^^^^ ^^^ ^ ^^ ^^^^^^^ ^^^^ ^^^ heria and other mfections probably in ^^^^ ^^ occasional disturbance is no- the order named as to frequency. ^.^^^ r^^^ p^l^^ intermits, or as is fre- quently said, skips a beat. By examin- I I I I I I >t ^^^ ^^^ heart, it is found that a ventricu- A I I I III ^^^ contraction of the heart occurs be- P P P \ \ \ ^^^'^ ^^^ rhythmic beat is due. This heart \ \ \ \^ \^ \^ pulse is not only premature in incidence, ■ ■ I III'' ^"^ ^^ weak; so that the impulse in most III ■ ■ B instances is not communicated to the radial pulse. After this beat, there is a Fig. 9. A diagram representing the normal Pause of unusual length. The impulses heart action. The auricle contracts first and producing these premature contractions transmits an impulse (represented by oblique sometimes arise in the auricle, but more line) to the ventricle. The ventricle responds qHq^ in some irritable foCUS in the Ven- and commences to contract immediately at the 4.»,j„]p ceesation of auricular systole. — Lewis. Fig. 10. A diagram illustrating the earliest Causes : stage of heart-block. An interval appears be- Often associated with mitral stenosiS, tween the end of auricular and the commence- with aortic incompetence, and oftener ment of ventricular systole. There is delay ^^,j^j^ degeneration of the heart muscle. in the transmission of the impulse from auricle y-, i ii j.i, _ • „-j. ^ 4--u^„^ ,,ri,^ i,*Tr« to ventricle (indicated by the increased ob- Probably the majority of thosewho live liquity of the line which joins the rectangles to middle or advanced life are affected at m the diagram.)— Lewis. one time or another with premature July, 1922 ORIGINA!. COMMUNICATIONS 341 contraction. It is found in rheumatics, in those who seldom take a vacation, in young men who smoke excessively. Fa- tigue, subsequent to exertion, is provoca- tive in all who are predisposed. It gen- erally disappears on exercise and when the temperature rises. It is easily recognized. The radial pulse presents either a prolonged pause or a feeble pulsation. Auscultation re- veals premature first and second sound or premature first sound alone, if the aortic cusps are not raised. Fijr. 22. The distrubance produced by a premature ventricular contraction (p) is rep- resented diasrammatically. The auricle beats regularly throughout. The ventricle responds to six auricular impulses. The impulse of the central auricular systole is ineffectual, for it falls while the ventricle is in premature sys- tole. The abnormal origin of the ventricular beat is indicated by the break in its centre. Note the equality in the lengths of perioiJs a and b, c in the compensatory pause. — Lewis. Case No. 2. Recently, I was examining a brother physician for indisposition following ex- posure and exhaustion. I was surprised to find that, occasionally, the pulse inter- mitted. Palpation and auscultation of the ventricle showed that there was a weak contraction of the ventricle com- ing earlier than the usual contraction, and then followed a longer pause than usual. This weak contraction did not reach the aortic cusps, nor produce any radial pulse. This is premature contrac- tion or extrasystole as it is sometimes called. It disappeared soon afterwards when the patient's temperature rose. IV. Paroxysmal Tachycardia. This term is restricted to cases that usually present a normal heart mechan- ism, but from time to time the normal action is interrupted by a series of rapid and regular beats, the series starting and ending abruptly. The pulse varies in rate between 100 to 200. True paroxysmal tachycardia is abso- lutely abrupt in onset and absolutely sudden in cessation. The rapidity per- sists for a few minutes or for weeks. It is a continued, rapid succession of pre- mature beats, arising from an irritable focus located, usually, in the auricle, rarely in the ventricle. Fig. 34. — A diagrammatic representation of a short paroxysm of tachycardia arising in the auricle. The abnormal auricular beats are broken in their centres. Each yields a ventri- cular response. — Lewis. Case No. 3. There is a lady under my general care who, for several years, has had occa- sional attacks of tachycardia. The at- tack comes on usually in the middle of the night and there is a feeling of con- striction or compression across the chest, palpitation of the heart, a pulse of about 200 and an anxious, distressed condition that makes her feel as if death is impending. This condition lasts for 2 or 3 hours when the pulse suddenly becomes normal and she lies down ej*- hausted, is nauseated and vomits fre- quently for 2 or 3 days. These attacks occur at irregular intervals of several months and except for slight apprehen- sion of a return, she feels comparatively well during the intervals. Graphic rec- ords show nothing abnormal during these intervals. This is a case of par- oxysmal tachycardia. V. Auncular Flutter. Auricular flutter is a condition in which an abnormal focus in the auricle gives rise to rapid, regular impulses which cause the auricle to contract at 200 to 350 per minute. Lewis describes this pathological wave as following a cir- cular path requiring 1/200 to 1/350 of a minute to complete the circuit. Thera is a partial failure of conductivity of the impulses to the ventricle — usually only half the impulses get the response in the ventricle making, in reality, a 2 :1 heart- block. 342 SOUTHERN MEDICINE AND SURGERY July, 1922 Digitalis is the remedy indicated. It tation or palpation, and there may be a may change flutter to fibrillation and difference of 20 or more. This is due to then, after the drug is discontinued, nor- the fact that some of the ventricular con- mal rhythm is restored. tractions are so weak that they fail to raise the aortic cusps and so the impulse fails to reach the wrist. Effects of Exercise. The irregularities of fibrillation are increased by exercise and decreased by rest. The contrary is true of other ir- regularities of the pulse — ^they decrease on exercise and increase on rest. Fig. 38. A diagrammatic representation of auricular flutter. The contraction wave in the auricle is represented spirally, to indicate its continuation and constant re-entry of the same path. The auricular rate is extreme; the ven- tricular rate is also rapid, though in this in- stance only half the auricular; 2: 1 block ^^^ ^^ ^ diagrammatic representation of piesent. Lewis. auricular fibrillation. The fibres of the auricle do not contract co-ordinately. The contrac- VI. Auricnlar Fihrillation. tion waves, which are multiple, follow varying Auricular fibrillation is a condition in and sinuous paths, colliding with each other which the normal, regular impluses aris- «^ re-entering tracks through which they or ^, , ., ,, 1 M their neighbours have previously passed. Oc- mg m the heart S pacemaker are re- cassional impulses leave the auricle at ir- placed by numerous abnormal impulses regular intervals, and many of these proceed arising in various irritable foci in the to the ventricle and stimulate it. Its action auricle. The waves of the impulses is therefore rapid and irregular.— Lewis. travel continuously in a haphazard way, very like waves of water when a series Case No. 4. of pebbles are being constantly thrown A man, T. C. M., age 35, entered the into it. The result is that the auricle hospital December 7, 1920, complaining is thrown into a sort of fibrillary tremor, of insomnia, breathlessness, and pain in Some of the haphazard impulses reach the region of the heart. His pulse was the ventricles and there induce haphaz- absolutely irregular in rate, rhythm, and ard ventricular contractions, irregular volume. The rate averaged about 100. as to rate, rhythm and volume — Delir- Auscultation showed tumultuous disor- ium Cordis it is called. der of the ventricle. For an instant. The Pulse. ^^^ could seem to hear first and second The pulse" in auricular fibrillation is heart sounds— then only one sound was usually rapid, 120' or more, but occasion- P^'^f "^ ^^d it was difficult to say wheth- ally is slow. The characteristic thing is ^^ 'I ^^^ first or second. A count of the that it is absolutely and continuously ir- ventricular contractions and pulse beats regular. It varies in rate, now fast, now "^^^^ at 'the same time showed a differ- slower, in rhythm and in vloume. ^nce of 20, the pulse being 100 and the Ventncidar Contractions. ventricle 120. This is called pulse defi- T, 1 .• 1 1, ,. 1 cit; and with the irregular pulse and dis- Palpation and auscultation reveal a ^^^^^^^ tumultuous ventricle, presented disordered, tumultuous action of the ven- ^ ^^^^ ^^ auricular fibrillation, tricles^ First sounds and second sounds slight exercise increased the heart are difficult to distinguish and the ear ^^^^ ^^^ ^^^^^^ ^^^ irregularity to be- may be confused by a Babel of sounds. ^^^^ ^^^^ pronounced. Morphine was given for a while to relieve the pain and Pulse Deficit. There is a del >mpared with the ventricular beats either by auscul- Digitalis was given freely in full doses. There is a deficiency of pulse count as secure sleep. The Wassermann was compared with ventricular rate. Count positive and specific treatment given. lllUl July. 1922 ORIGINAL COMMUNICATIONS 343 His pulse was regular January 5, 1921, oedema of the legs. The blood pressure when he left the hospital. had been about 180 to 190, but had drop- VII. Alternation of the Heart. Ped to 140. The pulse which had been This is a condition in which every oth- about 88 was about 44. Three possible er ventricular beat varies in strength, diagnoses were suggested : He had been producing a similar variation in pulse, taking digitalis in the form of digitahne or an intermittent pulse. It is associated hypodermically for about a week and the with conditions which produce exhaus- first supposition was digitalis accumula- tion of the heart muscles. It is a defici- tion with heart-block as in Case 1 al- ency in contraction of the muscles of the ready mentioned. This was ruled out by ventricle and not a defect in conductivitv finding an auscultation and palpation of impulses from the auricles. that the ventricles contracted at 88 per minute, one-half of the impulses not reaching the radial artery. The diagno- iss then lay between premature contrac- tion of the ventricles and alternation of the heart. If the former, then the ven- tricular impulses would show one short and then one long interval. If the latter, the intervals between the stronger and F,K. 51. A diagrammatic representation of ^^aker impulses would be the Same. As alternation of the heart. The auricular and a matter of fact, the latter was true. The ventricular beats are placed regularly and in impulses were regular, but every alter- order, but alternate ventricular contractions nate one was weak. This was a case of are week.— Lewis. alternation of the heart. Digitalis of better quality was given and the patient Case No. 5. promptly improved. In examining a patient. Miss K. S., Suyyinmry and Suggestions for Treat- who came to the hospital with a history yneyit. of arterial hypertension, insomnia, and l. Sinus Arrytlimia — found chiefly in dyspnea, I applied the cuff to take her children. Disappears on exercise. It blood pressure. Her radial pulse had calls for no treatment, previously been counted at about 100. 2. Premature Contractions— lessen or In taking her blood pressure, I found disappear when the heart is accelerated that as the sound first appeared at the ^y emotion, fever, or exercise. Cardiac elbow, I counted only 50 per minute. I drugs, as a rule, are not indicated. Mul- immediately felt the other arm and ^iple premature contractions indicate found the pulse there was still rapid, myocardial insufficiency, call for rest. Presently, however, as the pressure was ^^d careful attention to the gastro-intes- reduced, a second, weaker sound ap- ^inal tract, and to any systemic or focal peared between the first, slower sounds infections. Bromides are sometimes and it recurred regularly. B P 200-100. useful— digitalis when the heart muscle This is an example of alternation of the jg exhausted. heart, every alternate beat of the ven- 3', Paroxysmal Tachycardia — liavid tricle producing a weak impulse that j-^te, absolutely abrupt in onset and ab- was not recognized at the wrist, but was golutely abrupt in termination— not af- detected with the blood pressure appara- fected by position or exercise— often cut tus. This patient died two weeks later, ghort by pressure on the vagal nerve. Ossacionally it is not detected in the arm Neuropathic cause should be sought for at all, but can be detected in the chest, ^nd treated. Digitalis only when heart Case No. 6. muscle shows signs of exhaustion. A physician past middle life had for 4. Auricular Flutter — rarely seen, several years been suffering with arte- May be suspected when very rapid, reg- rial hypertension. When seen in consul- ular pulse is suddenly halved. Treat- tation, I found him sitting up panting ment — practically the same as for fibril- for breath, and with considerable lation, viz., digitalis. 344 SOUTHERN MEDICINE AND SURGERY July, 1922 5. Auricular Fibrillation— Absolutely ILLUSTRATIONS OF DIFFEREN- irregular pulse— irregular in rat^-in TIAL DIAGNOSIS OF SOME TOR- rhythm, and in volume-disordered ven- ^'jj!p ^^j^^^g^, ^'™ ^^^^^ ^^^^' tricular action — heart beats usually faster than the pulse. Exercise increases the irregularity. Treatment : Digitalis By Tom A. Williams, M.B., CM., Washington, D. C. „ ., , ..^ . ^ • .,. , Unconsciousness is one of the earliest or one of its substitutes. Quinidine sul- i i. i • u u- u vt uiiic J5U1 ^^^ most alarming phenomena which phate has been used successfully by sev- attracted the attention of students of eral clinicians. Atropine, belladonna disease. This is not the place for his- and hyoseyamus are to be avoided — they torical survey of the views regarding increase the pulse rate. consciousness or its loss. For this pres- entation is to be confined to some as- 6. Heart-Block. Most of ten seen with pects of differential diagnosis of some pulse rate of 50 or less. Sudden drop of the causes of impairment of con- while taking digitalis or during conva- sciousness of the more acute kind. It is lescence from acute disaeses are sugges- merely a survey of a few cases, the su- , . . -r, + «? 4- J u ,4- lu+i^ K,r perficial resemblance of which made the tive signs. Rate effected but little by ^ ^- -, ,■ • n ^.i ^ differential diagnosis all the more im- exercise — extreme cases produce uncon- portant. sciousness and convulsions (Stokes- Ad- The first patient was a man of 22, ams syndrome). ff" at Spartanburg, with Dr. Fike there. Three weeks previously there Treatment : No treatment is needed, ^^d suddenly ensued a feeling of stress as a rule. Digitalis not to be used. Epi- in the eyes as if congested, and this was , . u ij u • « ^r. followed by an excited delirium. From nephrin or atropine should be given in ^^.^ ^^ ^^^ ^^^^^^ .^^^ ^ ^^^^^ ^^ ^^^_ severe cases. por. When I saw him, there was less 7. Alternation of the Heart— easily evident, but there was still some cloud- , , , , ing of consciousness and slowing of re- recognized by the use of blood pressure ^^^^^^^ ^^^ movement, and inability to apparatus or in cases of halved pulse, by understand unless remarks were quite comparing radial pulse with ventricular simple. However, physical examination „,.,, , ^ . , ,. showed absence of left achilles reflex, beat. With hypertension and cardio- ^j^i^^j^i^^ ^f ^^e right adductor reflex, sclerosis, it indicates serious heart weak- ^ weakness of right internal rectus, an ness and a fatal issue is not far off. impaired diodocokinesis, slight jerky „,.,, 1 ui J -4. ,v,o,r v^o tremor in movement, a dull facies, and With normal blood pressure, it may be ^.^^ ^^^ ^^^^^.^^ p^p.^^ ^^^^^ ^.^^^ relieved by supportive cardiac drugs ^^ conjunction with the rapid onset, the such as digitalis. . delirium and the torpidity pointed to encephalitis as the possible diagnosis. Bibliography ^^^^ opinion was confirmed by the fur- ther progress of the case, the patient McKenzie-Oxford Medicine, Vol. V. markedly improving. Lewis-Clinical Disorders of the Heart. This case must be contrasted With the „ . young man now presented. S. Calvin smith-Heart Affections. ^^^^ ^^^ ^^^^^ ^^^ ^^^^^ ^^^.^^^^^ F. M. Smith — American Medical Association, Vol. 78, No. 12. Hatcher— American Medical Association, Vol. 25, No. 7. stooped shoulders, with the head poked forward with a set and staring look, the shortness of the steps in walking, the Wolferth— Quinidine Therapy in Heart Dis- *Read before the Tri-State Medical Associa- ease. Medical Clinics of North America, Vol ^ion of the Carclinas and Virginia, Norfolk, 5, No. 3. Va., February 22-23, 1922. July. 1022 ORIGINAL COMMUNICATIONS 345 lack of briskness of movement. Palpa- drome may appear as in the foregoing tion discovers a rigidity of the limbs, case. trunk and neck, and the patient com- Tn the extremely torpid cases, cata- plains of pain of the muscles above the lepsy may occur, and in that case there shoulder. This state is the sequel of may be a temptation to diagnose cata- an encephalitis which had been diagnos- tonic dementia praecox. Careful neuro- ticated as irfluenza some two years ago, logical study should prevent this error, in spite of the extreme lassitude and which the future course of the case will, torpidity of the patient during attack, however, rectify. A number of cases of this kind are One has to differentiate encephalitis now being seen by neurologists. In some from such a case as the following where of them tremor is a marked feature, a man of 44 as seen with Dr. Steedly, They present the syndrome produced by also at Spartanburg. Four months be- lesions in the region of the corpus fore be had had an apoplectic attack, striatum. Some physiologists believe blood pressure 198, followed by torpor, that in this region the injury falls upon headache in the left temple, aphasia a system which govern the muscles tone, and weakness of the right side. In hos- lesions of which produce both rigidity pital the blood pressure fell to 140 and and tremor without preventing volun- he improved, but relapsed three months tary movement, which, however, be- later with periods of semi-conscious- comes impaired on account of excess of ness. muscular tension. Examination showed an extensor re- The resemblance of this syndrome to sponse of the right plantar reflex, ab- Parkinson's disease is very striking, sent right abdominal, diminished cre- The differential diagnosis is made by the masteries, a weak grip of the right hand, onset of the former occurring after an diodocokinesis impaired on both sides, acute illness, encephalitis, and by its perseveration of movement, possibly comparative rapid onset within a few some apraxia, subatitutary aphasia and months, while Parkinson's disease oc- poor comprehension, though automatic curs insidiously during a period of years, speech was better than responsive Also, it is very rare except during the speech, and neither showed dysarthia. decline of life whereas post encephalitic Wassermann reaction was negative and dystonia may occur before the prime of the spinal fluid contained ten cells per life as in this case. cubic millimeter. There had been stra- Much misconception occurred from bismus. The visualfields were not ex- the use of the name "lethargic," as tor- amined at the time and there was slight pidity is by no means constant in en- diplopia but not hemianopsia. Nothing cephalitis. Restlessness on the contrary abnormal could be seen in the optic disks almost always occurs, although it may and there was no pupillary deficiency, not show itself for months. Wakeful- There was slight facial asymmetary. ness may be the predominant symptom The most significant feature of case and may last formonths. Oculo motor was that on sitting up there occurred paralysis may be absent even though excruciating pain in the left temple, the disease is a diffuse one, the fre- dizziness, and an aggravation of the quency of its occurrence is due to the speech defect. The man in every way concentration of the oculo motor cells except in his nervous system was in the in nuclei and to the delicacy of their best of health, with a blood pressure functions, the impairment of which is never exceeding 140. easily detected. On the contrary a le- In so powerful a man, free of renal sion of equal severity in the centrum disease or hypertension, one had to re- ovale may show no focal signs. In some ject the earlier diagnosis of apoplexy, cases the functions are well performe 1 The severity of the relapse and the late- until months after the development of ralization of the physical signs were the disease when a Parkinsonian syn- against a diagnosis of encephalitis in 346 SOUTHERN MEDICINE AND SURGERY July, 1922 spite of the suddenness of the attack, flexion. There was no paralysis and no On account of the onesidedness of the anaethesia, so far as could be ascer- signs, and their severity the aphasia, tained. The optic disk was not oede- the hemiplegia, the perseveration and matous and showed no arteriosclerosis, above all the localization of a headache but the superficial vessels had thick- though aggravated by change of pos- ened coats, though the heart was small, ture, the diagnosis made was a neoplasm the apex reaching only to the lower of the left frontal lobe. border of the fourth rib, one inch in- Another variety of torpidity is ex- side the nipple line, emplified in a woman of 45, seen near Systolic blood pressure was 102, the Rutherfordton, N. C, because pf a coma diastolic 60. The kidney function had with delirum which had occurred two been ascertained by Dr. A. Hooe to be weeks after a febrile attack with pain normal, phthalein appearing in ten min- in the chest. She had lost appetite for utes, and to the amount of 30 per cent, a considerable time and had been se- and 34 per cent, in the first and second verely constipated and had emaciated hour, respectively. But there was a greatly. large quantity of indican and a slight Examination found equal reflexes, re- trace of albumin, acting pupils, normal sensibility drag- The patient was taking the following ging movements and a lucid though very diet and medication : 2 a. m., beef juice ; sluggish mind. The skin was rough and 3.20, ammonia ; 4, red solution potas- dry, and there was a bran-like eruption slum iodide; 5.30, grape fruit juice; back of the wrists, the tongue was 6.15, three tablets, egg, whiskey, milk; scarcely red, but on inquiry the family 7.30, ten drops B. B. adrenalin solution ; doctor said he had remarked its extreme 8, ten drops solution iodide potassium ; redness two weeks before. Inquiry 10.20, soft toast, coffee; 11.15, three showed that there had been a great lack tablets — caffeine, strychnine, sparteine ; of variety in her food for the preceding 12, ten drops B. P. ; T2.30, ten drops six months, it consisting almost entirely solution; 1.30, beef tea; 2.30, ammonia; of grits and molasses, as she did not 3.30, three tablets; 4, custard, cream; care for meat, and green vegetables 4.30, ten drops B. P. ; 4.45, ammonia ; were almost unobtainable. 5, ten drops solution; 7, egg, whiskey, The absence of neurological signs in milk, a case of acute onset, and the quality of Marked Confusion Due to Metabolic the torpidity quite unlike that seen in Migraine Resetting Petit Mai. encephalitis caused a rejection of that A bacteriologist, aged thirty, was re- diagnosis, while the read tongue, the ferred to the writer in the spring of rapid emaciation, the eruption on the 1912, because of attacks he called "bil- wrists and the history of dietary diffi- ious" (but not preceded or accompanied ciency led to the diagnosis of pellagra, by constipation), which produce head- in spite of the absence of diarrhoea. ache, preceded by numbness and prick- Post-Influental Confusion With Exhaus- ing in the fingers, followed by dizziness, tion. mental confusion, and foolish talk of In May, 1915, judge, aged sixty-four, paraphasic type, without loss of con- after a sever attack of influenza, re- sciousness. These attacks had occurred mained very weak, confused in mind, every two or three months since the age and began to develop hallucinations and of twenty-two ; they were of short dura- delusions of a vague character. Several tion ; there were no scotomata, but they consultants were seen without result, were formerly accompanied by vomit- and he became weaker and less clear ing. The headache was of the splitting mentally. The patient was in a typical kind, lasted all day, and was followed by condition of mental confusion. Deep re- dullness and slowness of thought the flexes were very faint, abdominal re- day following. The capacity to concen- flexes were absent, there was plantar trate his thoughts was increasingly im- July, 1922 ORIGINAL COMMUNICATIONS 347 paired even between the attacks. He was fruitless ; so psychomotor exercises was at times irritable. He had no bad were begun for the facial tics. The habits, and apart from these attacks, he only effect of these was to arouse the was well and strong. He received a blow patient's resentment, and they were not on the side of the head when a boy, continued. Some time after, great and there was still a dent in the left somnolence manifested itself, the child parietal region, upon which side the becoming very lethargic and even drop- headache most often occurred. He had ping off to sleep in the middle of a task a large appetite, which he said he con- or at the table for a few minutes. This trolled, but he ate meat thrice a day, directed attention to the function of the although, he said, sparingly. The blood pituitary gland; so this was immedi- pressure was not raised, and reflexes ately explored by the laevulose test. As and sensibility were normal. this showed great increase of the tol- Treatment and Progress. erance of the system to large amounts He was given the low protein "stand- of sugar, 300 grammes, it was decided ard" diet. He wrote me the following that the pituitary gland was function- winter: "Since I have reduced the ing insufficiently; great increase of amount of protein in my diet and in- weight, torpor, psychic inadequacy and creased the quantity of vegetables, I its attendant changes in behavior being have had no recurrence of these spells." symptoms of lack of pituitary secretion. His physician informed me that he re- Feeding with increasing doses of pitui- mained well to date, over three years tary gland was at once begun. The later. child recovered completely in a few A mechanic of 48 was seen with Dr. months, and after the onset of puberty W. Carr, Jr., some years ago. He was was able to dispense with the pituitary quite unable to work, because of ex- gland, and now, 11 years later, is active treme depression, slowness of thinking and comparatively thin, and finally a state of torpidity from Hypothyroid Torpor. which he could scarcely arouse himself. A case mentally even more sluggish Examination showed loss of weight, was seen in a woman of 50, but in con- sluggishness of reflexes, slowness of trast to the preceding example she had movement and difficulty of cerebration gained 30 pounds in weight in the course along with a very sad feeling tone. The of a few months, the voice had become pulse was slow, and the blood pressure coarse and rough, there had been pro- below 90. gressive and constant loss of hair, the The clinical picture was typical of eyebrows had become scanty, the crines hypoadrnia and the diagnosis was con- less abundant and she showed the char- firmed by recovery within a week by acteristics thickening at the base of the attention to general hygiene and the neck, low temperature, slow pulse and giving of adrenal substance. rough skin of hypothyroidism a diagno- Pre-Adolescent Hypopituitarism. sis confirmed by her rapid recovery A girl, aged eleven years, was brought when thyroid substance was given her by her mother, a doctor's wife, because by the mouth. of loss of interest in her lessons, of Of the torpid conditions ensuing upon which she had previously been very psychic causes, of which an example fond; grimacing of the face in spite of would take too long to relate completely all correction ; equivocation and fibbing enough, the therapeutic import of a cor- in attempts to evade her duties; and rect diagnosis is just as great; for it is greediness amounting to gluttony. She especially to these patients that have had always been a stout child, but had been misdirected so often medicinal and become enormously so during the pre- physical measures without efficacy in ceding year or so. such cases. Strychnine, forced feeding. Exploration of a possible psvchologi- rest, cha'ige of scene, douches, massacre, cal cause for this change of behavior treatment by cults, all fail to reach the 348 SOUTHERN MEDICINE AND SURGERY July, 1922 source of the disturbance. The inertia vain hope of relaxing his over tight of cases of this kind can be quickly and muscles. infallibly removed, by proper psychic The patient with a tumor of the fron- means, and by them only. For if other tal lobe is relieved by an operation upon means, in some few cases, seem effica- the skull, he, too, is spared the infliction cious, it is only because of the psychic of mercury and arsenicals. accompaniments which some of them The woman with pellagra escapes the sometimes contain, and which may acci- mad house, useless medication, futile ex- dentally happen to fit the particular ploratory operation and is quickly re- case, whereas intelligent psychotherapy stored by appropriate diet, ascertains and measures the situation The young girl with pituitary disease and then meets it with a sure hand. is spared the stigma of a perverse char- A torpid state has been observed by acter, the trying discipline of psycho- me as a reaction to an over difficult sit- motor re-education, and the murdering nation. Thus one of my friends, an of the digestive organs by so-called ton- eminent inventor, who keeps up a pri- ics. She was soon restored to effective vate laboratory for his amusement, finds living by proper opotherapy, that whenever he fails to solve a prob- The man who at first sight seems a lem upon which he has been working wreck of his former self is spared the for some hours he is not only disap- all too commonly imposed trip to Flor- pointed but has an irresistable inclina- ida, a long stay in a sanatarium, or life tion to sleep which he indulges, although of permanent invalidism. He, too, is he can be overcome with a powerful quickly restored to effectiveness by stimulus. proper opotherapy. Again a young lad of my acquaint- The woman who has become a bur- ance when faced with something which den to her household, and whose illness he finds unpleasant feels himself over- is compelling her family to face an en- come with a species of lassitude and tire readjustment of their lives is re- complains of being very tired. This stored to her former effectiveness as state is very easily dissipated by either director of her household, and compan- changing the mental attitude towards ion of her husband and children; but his task, or permitting him to do some- only after the nature of her trouble is thing else. In some instances, however, ascertained to be due to a mere defi- lassitude will persist for a considerable ciency of thyroid secretions, time. Treatment. Although curious and interesting re- SURGICAL SIGNIFICANCE OF PAIN lation of these cases would have little ^^ THE LEFT SIDE OF practical import for healing the sick did ABDOMEN differential diagnosis not provide an By R. L. Pittman, M.D.. Fayetteville, N. C. avenue to treatment of each case lead- j^ j^ ^^^ ^y intention to enter here- ing to improvement and recovery. Thus j^^o the general discussion-differen- the case of acute encephalitis was spared ^iate diagnosis and treatment of the the risks of exploratory craniotomy, n^j^erous conditions likely to produce avoided an unnecessary saturation with ^^^ -^^ ^^e left side of the abdomen, antiluetics and was spared the expense ^^j^j^gj. ^^ j ^^^^ ^^ ^^^e up conditions rich diet. usually produced by general pelvic in- The patient with post-encephalitic flammation in which the uterus, tubes, dystonia is saved from wasting his ovaries and sigmoid are all matted to- money upon useless manipulations gether by adhesions. My reasons for whether they call themselves chiroprac- tic or not and he is spared the annoy- . ''^^^,^ before the Tri-State Medical Assoc-ia- 1 J? t • ^ 1 i • tion of the Carolinas and Virgmia, Norfolk, ance and expense of being baked m a va., February 22-23, 1922. July. 1S22 ' ORIGINAL COMMUNICATIONS 349 presenting this paper was brought about unmarried woman or maybe the mother by having had several patients come to of two or three children, usually 25 to me for treatment — suffering with 35 years of age, with a history of pain- chronic and more or less severe pain in ful menstruation or with some difficult the left side of the abdomen and low labor, pain in the left side which ex- down across the back, in which cases tends all the way from the left anterior an eliminative diagnosis was the only spine up to the splenic flexure of the way to arrive at a diagnosis with any colon, obstinate constipation and in a degree of accuracy. With such patients few cases occasional attacks of diar- we have X-rayed the kidneys, including rhea. They frequently complain of pain the kidney pelvis, catheterized the ure- on defication with an expression as ters, eliminated enlargement of the commonly used by the patient — of a spleen, dislocated kidney, etc., all with stoppage. Thorough purgation usually negative findings in this particular con- relieves such patients temporarily — dition. Vaginal examination may or only to return when the sigmoid fills up may not reveal an inflamed condition again. There is no tenderness or rig- of the left tube and ovary. In many idity of the abdomen and it is difficult instances a dilated portion of sigmoid to say just where the pain is most in- can be palpated and on pressure a gur- tense. In my experience — pain has been gle can be detected as is sometimes no- more pronounced in lower left abdomen ticed in the region of cecum during and low down across the back, vaginal examination. X-ray examination under fluoroscope Our attention for the past decade or jg ^^ ^^^^^ ^xelv in the diagnosis of this I might say two decades has been di- condition although it is by no means rected almost entirely to the conditions ^^ ^^ depended upon as a final and of the right side of the abdomen and unquestionable diagnosis. The explana- upper abdominal region-at the same ^.^^ ^^^ ^^.^ .^_^^^ ^.^^^-^ ^^^ ^^_ time conditions in a similar way may ^^^^ .^.^^^ ^^^ ^^ ^^^ .^^^^^_ take place on the opposite side and it is attachments which are con- for this reason that I wish to call your . , ^ ' i ttt u ^ • a u attention to a few findings which has sidered normal. We have derived much been brought to our attention in some f^^m simply passing the tube up the of our cases. In 1907 Lane wrote his rectum and watching its ascent with first paper on the so-called Lane's Kink, fluoroscope— noting any point of ob- in 1909 Jackson presented the condition struction that it meets m the lumen of designated by him as a membrane, bowel and in this way a loop of the which was known as Jackson's Mem- sigmoid can usually be determined, brane. These two conditions were prev- These patients are or)erated upon bv alent in the region of the terminal ileum median incisions, pelvic inflammation is and cecum. In 1911 and 1914 Royster first looked after, diseased tubes or called attention to adhesions in the left ovary on the left side receives proper side of the abdomen. treatment and the sigmoid is examined My attention as stated before was thoroughlv. In some cases the sigmoid directed to this condition chiefly be- may be adherent as mentioned above to cause of the absence of findings which the. wall of the pelvis or to the tube or would otherwise explain pain which the ovary. In this event tension is made patient had, and upon investigation at on the upper portion of the bowel and the time of operation we have found in adhesions divided— a rectal tube is now several cases adhesions of the sigmoid past to make sure that the bowel has in its upper portion which are of an been freed and normal lumen of bowel obstructive and painful nature. has been restored. After freeing tne c, , ^. , „ 4. ^u _ sigmoid it is again placed m its normal Such patients usually present them- '"-iK'num & f selves complaining of the following position. The ascending colon is next symptoms : As a rule the patient is an examined— there we have found equally 350 SOUTHERN MEDICINE AND SURGERY July, 1922 as many adhesions as we have in the The condition was so acute that imme- sigmoid, in fact I have found in a few diate operation was deemed best and cases the position of the descending at the time of operation extensive ad- colon to be more disturbed than that of hesions of the sigmoid, with a marked the sigmoid. This is usually true in contraction of the lower two inches of the la'^t three or four inches of the de- the descending colon were found with scending colon. In this portion of the almost a band-like condition at this bowel it is abnormally plastered down point. The adhesions were freed and to the abdominal wall, almost rigid and treated as mentioned above — the pa- in many instances smaller than the nor- tient made an uneventful recovery. This mal bowel with what appeared to be a patient was operated on 14 months dilated portion above. As illustrative of ago — in answer to inquiry a short time these findings and results .derived from ago patient stated she was free of pain, operation as described above, I wish to had gained 10 pounds and constipation report the following cases, which will was entirely relieved, serve to substantiate results to be ex- Third: The third patient was one pected in such cases from such treat- who had gone the rounds including the ment. Osteopath, finally going to Johns Hop- First : Female, aged 34, chronic suf- kins Hospital and having thorough ferer of constipation, pain low down in X-Ray examinations. She was given a the back and left side. This patient report that she had adhesions of the at times would go anywhere from a sigmoid, descending colon and an in- week to two weeks without a bowel competent ileo cecal valve. This patient movement. Patient was very sallow was advised to have her appendix re- and a picture of chronic toxic condition moved and adhesions freed. In this in- which one would expect from intesti- stance I made a median incision, remov- nal stasis. This patient was an unmar- ed the appendix which showed evidence ried woman, did office work and was of chronic inflamation. I found a very naturally in a stooping position most all fixed condition of the descending colon the time. Her urine contained a trace and upper portion of sigmoid. This pa- of almumin, no casts, increased quantity tient had suffered severely from attacks of indican. Exploratory incision was of headache, nausea and vomiting and made, nothing found except extensive the most obstinate form of constipa- adhesions of the sigmoid to left tube tion with pain more or less over the en- and ovary which was normal. Adhe- tire abdomen, but worse in the left side, sions were freed and treated in the Pelvis organs were negative. This wo- manner mentioned above. I saw this man was married — 44 years of age and patient a short time ago— since the was the mother of five children. While operation which was two years ago this patient has not been entirely re- she has been greatly improved, com- lieved I have seen her at intervals and pletely relieved of constipation except she has doubtless been benefitted a for an occasional attack for only a day great deal. or two, general condition good, no pain Fourth: The fourth patient was an in the left side. unmarried woman 32 years of age, in- Second: Female, age 28, mother of definite history of pain in the left side, two children, the last delivery was by extremely constipated, relieved by pur- forceps and very difficult. This pa- gation— pain in the back in the region of tient was brought to the hospital with sacrum and coccyx, was very nervous a tentative diagnosis of absolute ob- and at times melancholic. She consulted struction — with a history of chronic a stomach specialist who gave her an constipation, pain in the region of the X-Ray examination with a diagnosis of ccccyx and on defication over a period chronic inflamation of the sigmoid and of one and one-half years, which was descending colon with adhesions. Ad- soon after the birth of her last child, vised an operation. This patient came July, 1922 ORIGINAL COMMUNICATIONS 351 to me for operation and the findings 9 cases had hemorrhoids present at in this case were similar to those men- the time of operation, tioned above. The sigmoid in its upper 3 cases had been operated on for two or three inches was very much hemorrhoids. smaller than normal, would hardly admit 2 cases for ischio rectal abcess. the finger and was evidently the seat of 1 case for fissure of rectum, incomplete obstruction or to say the 2 cases at time of operation had vari- least retarded the progress of intestinal cose veins of broad ligaments. Practi- contents. These adhesions were freed cally all of them were victims of ob- and while the patient was in the hospital stinate constipation, she required very little purgation — 6 cases were individuals who had fol- after the third day her bowels moved lowed office work or whose daily occu- regularly, and her general condition pation required them to be in a stoop- improved a great deal, sufficient to war- ing position almost constantly, rant her having had the operation. You will see from the report of these Fifth: Female — aged 34 years — no cases that something can be done for children — marked dysmenorrhea for a chronic constipation which has reached number of years — was curetted three the stage of finally producing adhensions years ago, practically no relief ; chief or at least being the result of adhesions complaint, pain in the left side. Oper- — their physical condition being such as ation: Both ovaries, had small clear to prevent them from performing the cyst present. Sigmoid looped over tube actual duties of life, and round ligament, well forward. This I do not think this diagnosis will al- was most marked case I have seen. ways be accurate, in some cases it can Sixth: Female — aged 36 — 3 children be depended upon but in others it is living and well. Patient picture of difficult to determine. Sooner or later marked intestinal stasis, loss of weight I believe considerably more attention — chief complaint at time of admittance will be given this portion of the intesti- was pain in lower left abdomen and low nal track and the left side of the abdo- down in back. Dilated condition of men will be considered a surgical entity bowels in region of upper sigmoid could in a proportion to its vital organs lo- be made out. Operation: Tube — ovary cated in the left side as compared with and uterus negative. The sigmoid that which the right side has justly re- formed a complete loop over the left ceived in the past. tube and round ligament to which it was permanently fixed. Etiology: The numerated conditions RADIUM THERAPY IN CERTAIN mentioned above as probable causes are BENIGN AND MALIGNANT purely speculative, based entirely upon CONDITIONS* the history and findings on physical ex- ^^ ^^^iju^,^^ D. James, M.D., and amination of patients at the time they Albert W. James, A.B., M.D. presented themselves for treatment — , ^^ ^ most common of these are hemorrhoids. The Hamlet Hospital, Hamlet, N. C. ischio rectal abcess, fistula in ano rectal Since radium has been added to the fissure, varicose veins of broad liga- general surgeon's armamentarium he ments, stooping position, constipation, finds he can accomplish more striking difficult menstruation, difficult labor, results in far less time than could be etc. obtained by the use of the X-rays. Par- * ticularly is this true in treatment of We find on searchmg our records j^^ng^ant conditions in the several cav- that we have operated on twenty-three j|.jgg ^f the body which communicate such cases in the .past two years which showed the following very inter- Head before the University of North Caro- * ■^ lina Medical Society, Chapel Hill, N. C, Jan- estmg findings to be present : uary 14, 1922. 352 SOUTHERN MEDICINE AND SURGERY July, 19:: almost directly with the exterior, as, for example, the uterus, vagina, maxillary sinus, rectum, pharynx, and others. The main reason for this is that the radium container can be placed in direct con- tact with the area of disease, within the cavity, and left there for the necessary dosage. Upon the skin surface, radium is preferable to the X-rays, because of the concentrated and selective action of its rays upon embryonal and malignant tissue cell, the ease with which the cases can be handled, and, of prime im- portance, the striking results which usually follow. In considering the effects 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 do not cause burning or irritation. Owing to its high penetrating power, the gamma ray is commonly spoken of as the ther- apeutic ray of radium. It acts directly on the nuclei of malignant tissue cells, and, since they are embryonal in na- ture, they are destroyed before the nor- mal tissue cells are appreciably affected. The alpha rays are soft and of no prac- tical value in radium therapy. The beta rays are of value in cases where the ra- dium is applied directly to the lesion. If normal structures intervene between the pathological tissue and the surface to which the radium is applied, one must screen the radium so that the alpha and beta rays are absorbed to such an ex- tent as to prevent a burn on the normal tissue. 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 under- lying layers, which may result in a sur- face injury, or so-called burn. Where the radium can be brought in direct contact with the malignant tissue and only superficial effects are required, the beta rays are very useful. The metal containers and screens induce short sec- ondary rays, which are irritating to normal tissues, if the precaution is not taken to absorb these in rubber tissue, which is usually placed about the whole radium body. Different screens and fil- ters are used, as may be indicated by the particular case. These will not be dealt with in detail, for they are prob- lems to be worked out in each case. The dosage is expressed in milligram- hours, this representing the number of milligrams of radium multiplied by the number of hours used. However, there is likelihood of error to use the term "milligram-hours" because it leads one to think that the only factors which enter into the specification of the dosage are quantity and time, whereas the fil- tration and distance from the radium to the pathological lesion are equally important. The dosage demanded in each case is readily determined after a certain amount of experience. Within certain reasonable limits, the same re- sults may be obtained by increasing the quantity of radium in the same pro- portion in which the time exposure is decreased, and vice versa, but extreme variations are not covered by this gen- eral rule. Of the benign condition, fibroid and fibro-myoma tumors of the uterus af- ford the most pleasing results. The two contra-indications to radium ther- apy in these fibroid uteri are general fibrosis of the uterus, where the organ is so large that it practically fills the entire abdominal cavity, and peduncu- lated sub-serous fibroids. Obviously, these two conditions are more amena- ble to surgery, because of the remote- ness of the growths from the point of application of the radium containers. In cases suitable for radium therapy, the cervix is dilated and the radium is in- serted into the body of the uterus for an average dosage of four hundred mil- ligram-hours. Five to seven such treat- ments usually cause the tumors to dis- appear. We are not so radical as to advocate radium therapy in all cases of fibroid uteri, though we feel that many cases should be given the benefit of the doubt and the conservative plan follow- ed. In operative cases of fibroid ulteri, we usually confine our procedure to July. 1922 ORIGINAL COMMUNICATIONS 353 supra-vaginal hysterectomy. Agreeing these conditions as pre-cancerous and with the teaching of Polak, that malig- treat them accordingly with radium, nancy does occur in the cervical stump The result is practically one hundred after supra-vaginal hysterectomy in per cent cures. many cases, we feel that post-operative Often after bone injury, or from dis- radium therapy is the ideal phophylaxis eased bone, or from an old thoracotomy against this. The mortality rate in wound after rib resection in empyema, supra-vaginal hysterectomy is consider- there will develop a discharging sinus ably less than in total hysterectomy, which is persistent. Radium containers and the same end results are being ob- placed in these sinuses serve to pro- tained when radium is applied to the duce a mild stimulation to the tissues, cervical stump after supra-vaginal hys- regeneration occurs, and the sinus terectomy without the additional mor- heals, tality rate of total hysterectomy. The one great field of radium therapy Lupus vulgaris responds more favor- lies in the treatment of malignant con- ably to radium treatment than to any ditions. A paper so short as this one other procedure. The area is treated will not permit minute descriptions of with full strength radium placques, any particular conditions. For this rea- screened with one to two millimeters of son, we wish you to rely upon visualiza- aluminum and filtered through two or tion of many of the malignant condi- three millimeters of rubber tissue. The tions which radium will benefit by a same technique is employed in treating study of the photographs of cases to pigmented moles and naevi, though in be shown in a few minutes. While it these two conditions the results are is clearly shown that many bad cases of slower and the treatment must be con- epithelioma and carcinoma can be cured tinued over a long period of time. Ke- with radium, one must not get the idea loids will disappear under radium ex- that it is a panacea for malignant con- posure, but slowly. The real place ra- ditions of no matter what degree of in- dium therapy occupies in treatment of volvement. It has its limitations, just keloids is to prevent recurrence after the same as any other therapeutic surgical excision. Concerning the treat- measure has, but at the same time the ment of moles, nothing should be said, range of usefulness of radium is greater Moles should not be treated with radium than any other procedure in the treat- unless they show signs of being irri- ment of malignancy. The earlier the tated, as, for example, where a man has case is treated, the greater are the a mole on his face and it is irritated chances of success. constantly by being shaved across. This Inoperable carcinoma of the breast is the time to remove the mole by ra- and recurrent carcinoma after radical dium exposure in preference to surgi- mastectomy yield more favorably to ra- cal excision, because one must truly re- dium therapy than to any other meas- gard an irritated mole as a pre-cancer- ure. This type of work requires heroic ous manifestation. doses and treatment continued over a In our section of the State, there are long time at frequent intervals. Even many people of Scottish descent, in in operative cases of carcinoma of the whom chronic skin irritations are quite breast, it is a good plan to use several common. These irritations vary from a large doses of radium before operation slight keratosis to epithelioma and car- to seal off the lymphatics, as well as cinoma. So common are they that the post-operative over the entire breast laity speak of the mild irritations as and axillary area as a prophylaxis "Scotch spots." Going into the histo- against recurrence, ries of many cases of well-developed The results of radium treatment of skin cancer, we find a large percentage inoperable carcinoma of the uterus are have started from these "Scotch spots." no less striking than those obtained in For this reason, it is proper to consider the cases of fibroid uteri, as mentioned 354 SOUTHERN MEDICINE AND SURGERY July, 1922 above. We have a series of some twenty- four cases of carcinoma of the uterus which had been treated with radium and the results have been highly satis- factory. With two exceptions, all of these cases were inoperable, many of which had progressed to a marked de- gree of involvement of the vaginal for- nices and adjacent tissues. To say that cures have been accomplished in any of these cases is too much like looking the proverbial gift-horse in the mouth. The results in the whole series have been gratifying and encouraging. Twelve cases have been discharged from treat- ment, but they are not pronounced cured ; they are kept under observation and instructed to report for examina- tion at stated intervals. Four other cases are about ready to be discharged under the same conditions as the first twelve. One pitifully hopeless case died from metastatic involvement of the liver, after treatment extending over a year. Even in this case, radium treat- ment prolonged life considerably by checking the uterine hemorrhages and alleviating the pain somewhat. One case died of intercurrent pneumonia when she was doing well under treatment. One case died after tTie first treatment; in this case the cancer was the most ex- tensive involvement of the uterus, va- gina, and broad ligament we have ever seen. The remaining five cases are un- der varying stages of active treatment. In carcinoma of the uterus treated with radium, the end results are some- times so good that we feel almost like calling them cures. Oftentimes the pa- tients are completely relieved of their distressing symptoms and there is no further evidence of the carcinoma to be made out upon examination. Likewise, we are tempted to advocate radium ther- apy of operable carcinoma of the cervix as the preferable procedure over total hysterectomy (Wertheim's operation). The two cases of operable carcinoma of the cervix which we have treated with radium alone have resulted in clinical cures. Time alone will prove whether or not radium will displace surgery in the treatment of operable carcinoma of the cervix; both sides of the question have their warm advocates. This paper has been somewhat lengthy and an apology is extended. It is only a superficial survey of a few of • the many conditions in which radium is beneficial. No mention has been made of the excellent results which have been obtained in cases of toxic hyperthyroid- ism, chronic mastitis, rodent ulcer, tu- berculous adenitis, some types of hyper- trophic tonsils, a few cases of cataract, and other chronic conditions. The field of usefulness of radium is surely limit- ed ; likewise, it is surely large. We are all on the threshold of an era when it behooves every large clinical center in the State to have its trained group of radiumologists, and the small commu- nity hospital to have its chief surgeon familiar enough with radium to treat the cases of his clientele, which need radium therapy and are not able to go to the larger clinical centers to obtain it. ACUTE PARENCHYMATOUS GLOS- SITIS, WITH REPORT, OF THREE CASES FROM THE EPISCOPAL HOSPITAL OF PHILADELPHIA. By Jackson K. Holloway, A.B., M.D. Acute parenchymatous glossitis is a rare disease. Many large hospitals have no cases upon records covering a long period of years. Only three cases have been observed in this hospital during the past 22 years. The literature upon the subject is fairly complete, however, probably because isolated cases have proven interesting. In December, 1921, two cases came under my observation within one week. These were essential- ly two different types in every respect, with one recovery and one death as the result. The disease may be defined as an acute parenchymatous infiltration of the tongue. It is usually caused by some germ and is characterized by excessive swelling of the tongue or portion of it, the process often progressing to sup- puration, abscess for gangrene. July, 1922 ORIGINAL COMMUNICATIONS 356 It occurs more frequently in males, protecting epithelium normal oral bac- The majority of cases fall within the teria become pathogenic. Normally in- age limits 20-40, but six months and 80 ert they but await a suitable soil upon years are the extreme ages recorded. It which to develop. is more prevalent during the winter Development by extension has been months, when body resistance is low- pointed out by Prenn. Follicular ab- ered, and in the country rather than scess of the lingual tonsil may by ex- the cities. tension through the lingual follicles Etiology — Exposure to cold and damp, transmit infection and thus be caused especially when associated with a run- to form abscess within the tongue. Oc- down physical condition and lowered re- casionally nasal operations, submucous sistance, is the most potent pre-dispos- resection, have been followed by acute ing cause. There should be mentioned glossitis. also as predisposing causes injuries to Pathology — The process is essential- the tongue as by biting it, sticking it ly a violent inflammation with violent with a fork, fish or meat bone or tooth lymph and round cell infiltration and pick; carious teeth, faulty dental work, swollen lymph vesse'ls. In idiopathic foreign bodies held in the mouth, cor- cases it is believed to be merely an rosive, hot liquids, insect bites, venoms, oedematous phenomenon, not an inflam- contact with cold metals, debauched mation. The connective tissue in the states. tongue is not very abundant; hence Idiopathic cases are sometimes seen in swelling may be almost unlimited. The scrofulous people, in convalescents from infiltration is chiefly in the inter-muscu- febrile diseases. Pepper mentioned that lar substance. Damage to the paren- it was especially imminent after influ- chyma is therefore due principally to enza but this does not appear to have direct pressure upon muscular tissues, been borne out during the epidemic of In cases advancing to suppuration, ab- 1918. Chewing certain acrid plants, eat- scess, or gangrene muscular fibres are ing certain foods, as celery and shell- destroyed in proportion to the severity fish, are to be mentioned. Ambrose of the inflammatory process. Pare reported two deaths from glossitis The inflammation may involve the en- following the drinking of a vinous po- tire tongue or merely a portion of it. tion impregnated with saliva of a toad The portion anterior to the lingual V (Pepper). is more commonly affected. There is a Occasionally glossitis occurs during fairly definite connective tissue septum an attack of scarlatina, variola, scurvy, running through the midline, which, typhoid, glanders or septicema. More however, becomes thin near the tip. In frequently it is secondary to diabetes, many cases this offers an effectual bar- rheumatism, mercurial poisoning, ton- rier to invasion of one-half the tongue, silitis, pharyngitis and toxemic stoma- This explanation of why one-half the titis. Occasionally it is associated with tongue may alone by involved is not uni- gastritis or epithelioma of the tongue, versally accepted. Duckworth regards Although the disease is usually an in- hemiglossitis as a catarrhal neurosis, fectious one, the specific organism can- Butlin believes it to be a parenchyma- not always be determined. Staphylo- tous inflammation of a superficial and cocci and streptococci have most fre- benign type, differing from general glos- quently been recovered in pure culture sitis only in the occurrence of a definite from selected cases. Various other bac- nodule, or lump, in the substance of the teria which normally inhabit the mouth inflamed part. This lump, he explains, have been blamed. Usually the mouth "may be present in many cases of gen- and tongue are naturally quite immune eral glossitis but the excessive swelling to germ infection. When body resist- prevents its being felt." ance is lowered, or when the organisms Cases have been reported where the are injected into the tissues beneath the attack was preceded by earache, appli- 856 SOUTHERN MEDICINE AND SURGERY July, 1922 cations to the tympanic membrane, or disease of the middle ear. Such have been considered as nervous phenomena. Gueneau de Mussy produced violent swelling of the tongue by galvanizing the peripheral end of the lingual nerve, which ceased when the chorda tympani was cut. In such cases the swelling is not necessarily limited to one-half the tongue. Lewis reports a case where marked swelling of the tongue followed 12 hours after application of chromic acid to the tympanic membrane for chronic purulent otitis media. Another similar attack was noted within 14 months. He attributed it to an angio- neurotic edema from irritation of the chorda tympani nerve which runs quite near the tympanum. In infectious glossitis there is a dif- ference in the staphylococcic and strep- tococcic types. When streptococci are causative there is characteristc local edema with danger of extension to the neck, glottis, lungs or pericardium. The infection may extend to the face and become typical erysipelas. In staphylo- coccic cases the swelling is localized, and there is little or no attempt to marked extension, unless there is a mixed in- fection with streptococci. Moreover, the formation of a well localized abscess is usual. When gangrene intervenes it is usual- ly due to pressure upon the tongue by the teeth. It is ordinarily limited to the portion of the tongue which is pro- truded beyond the teeth. Rarely gan- grene affects the intraoral portion of the tongue or involves it in its entirety. The affected portion may slough away, leaving a clean base and subsequent cicatrices. Frequently violent hemor- rhage follows sloughing. Symptoms and Diagnosis — The onset is usually so rapid that the clinician may not see the patient until the clini- cal picture is complete. There are, how- ever, certain prodromal symptoms. Usually there is a mild sore throat, rather acute lingual pain, neuralgic pains in the back of the neck, ears, and temporal regions, obviously due to the sensory distribution of the lingual and glossopharyngeal nerves. The lingual supplies sensation to the anterior two- thirds of the tongue and connects with the auriculo-temporal branch of the tri- geminal. The glossopharyngeal which supplies sensation to the posterior one- third of the tongue sends off a tympanic branch (Jacobson's nerve). The swelling of the tongue, which is characteristic, may come on gradually or quite suddenly. Usually it reaches its maximum in 24-48 hours. Some- times the prodrome is extended through ten days without definite swelling of the tongue. The swelling may appear quite suddenly, as within two hours. In such cases the onset is usually at night. The patient may awake to find his tongue immensely swollen. Whether one or both halves be involved, the tongue will generally be so swollen that it almost completely fills the mouth. A part may be forced outside. The intra- oral portion is dark red and moist, while the protruding portion is dry and livid, circulation being largely checked by pressure of the teeth. There may be teeth imprints and erosions upon the tongue. Upon palpation the tongue is found firm and uniformly as ''hard as wood." It may pit a little on pressure. Some- times there may be one or more points of resistance; and occasionally there is a soft point of fluctuation on the upper or under surface. This is especially so in hemiglossitis. However, this may not appear until the inflammation is well advanced and abscess formation has re- sulted. Generally there is slight enlargement and tenderness of the submaxillary lymph nodes. One or both sides may be involved. Occasionally they are very much enlarged, but very rarely suppu- rate. When the posterior half of the tongue is involved the cervical nodes may be affected also. The constitutional symptoms are quite characteristic. Pain is variable. It is spontaneous in some cases, absent in others. Where there is no spontane- ous pain marked pain may sometimes be provoked by slight manipulation of July, 1922 ORIGINAL COMMUNICATIONS 351 the tongue or even by touching it. Occasionally it is entirely absent. It is usually described as violent and shoot- ing. It may be definitely localized or shifting from one side of the tongue to the other. There may be marked tris- mus especially when the examiner pushed upon the mandible. This is due to contractions of the Masseters with rapid inhibition following encroachment upon the painful tongue. The tongue may be serrated against the teeth. The rugae are usually effaced. The swollen tongue makes speech un- intelligible and pain serves as a check upon attempts. Early in the onset the speech becomes very nasal, as in mark- ed angina or pharyngitis. Alongside this there is marked difficulty m mas- tication and deglutition. At the height of the attack even liquids may not be swallowed. There is usually interfer- ence with breathing, less marked where only half the tongue is involved than in total glossitis. The difficulty may be due to one or all of three things: (a) mechanical pressure of the swollen tongue upon the glottis and soft palate and pressing down of the epiglottis ; (b) edema of the glottis; (c) a momentary nervous suspension of the act of res- piration. Accordingly there are usually cyanosis of the lips, injected eyes, en- gorged face, and a picture of terrible anguish. Suffocation rarely occurs, though sometimes tracheotomy is nec- essary. Sometimes the neck is so swol- len as to injuriously press upon the jugular veins (Pepper). The patient is usually quite restless. He dribbles saliva freely. Whether there is an actually increased flow of .saliva has not been determined. Some consider the overflow as merely the nor- mal amount secreted but which is un- swallowed. The general symptoms are not particularly characteristic. Usually the fever ranges from 99.8 to 104 de- grees F., the pulse being rapid and more readily compressible than normal. There is loss of appetite, insomnia and sense of suffocation. There may be con- stipation. Where erosion, suppuration, or especially gangrene occurs there may be diarrhea and toxemia, due to the passing of toxic products or decomposed tissue into the gastro-intestinal tract. Occasionally there may be delirium, con- vulsions, prostration. Duperier explains that cerebral congestion is, however, not a symptom of glossitis, but rather a complication. In favorable cases the symptoms begin to abate within three or four days. Rarely are they protracted longer than eight days. Bennett cites one case which lasted 90 days. Resolution is indi- cated by return of moisture to the tongue, progressive detumescence, sub- sidence of pain and dyspnea. The con- stitutional symptoms quickly disappear and phonation and deglutition are re- stored. In suppurative cases local distress is usually protracted for about a week. Pain is more severe. Abscess may be suspected but remain undiscovered. In such cases spontaneous rupture and xit of pus quickly leads to recovery. In cases progressing to gangrene there is a livid appearance of the part undergoing mortification. This may be localized or diffuse. Gangrene is indi- cated also by "marked adynamic symp- toms upon the part of the constitution," according to Bennett. A characteristic odor accompanies gangrene. Certain conditions which cause a swelling of the floor of the mouth may closely simulate glossitis. Acute infec- tion, salivary cysts, phlegmon and tu- mors may be mentioned. As a rule in these cases the pain and swelling of the tongue itself are not very marked. The chief point of differentiation is this : in glossitis the tongue is affected; in phlegmon of the floor of the mouth (Ludgiw's angina, etc.) the tongue is not affected, but the floor of the mouth may rise above the alveolus. Moreover in glossitis the tongue is pushed for- ward and is projected beyond the dental arcade; while in affections of the floor of the mouth the tongue is pushed up- wards and backwards. Thebaud points out that in phlegmon of the buccal floor the swelling is chiefly "sushyoidienne," 358 SOUTHERN MEDICINE AND SURGERY July, 1922 while in glossitis the swelling is chiefly within the buccal cavity. Treatment — In all types the initial treatment is to give a saline purge. A certain number quickly recover without further treatment. This is especially true of the non-infectious types. It is therefore the part of wisdom to deter- mine the causative factor if possible. Long deep incisions are unnecessary in some of the non-infectious types of glossitis. Butlin states that in hemi- glossitis the treatment consists of a purge, followed by a drink of chlorate of potash, liberal liquid diet, local ap- plications of cold or where warmth is more acceptable warm gargles or bath- ings of the tongue with solutions of bo- rax or potassium chlorate. It is doubt- ful if this idea is adhered to generally. Where pus is suspected the treatment is surgical. The inquiring scalpel fre- quently finds pus where the diagnostic finger fails to appreciate localizing signs. An incision made over a fluctu- ating point is too frequently rewarded by evacuation of pus and rapid relief of symptoms to make medical treatment the treatment par excellence. More- over, it would seem that though the re- sults may be ultimately as good in un- operated cases yet the period of recov- ery is longer. Spontaneous rupture of abscess, which frequently occurs, is Na- ture's surgical treatment but it is not devoid of danger, especially when it oc- curs while the patient is asleep. In some cases where a pus pocket is not incised the condition becomes chronic. Hahn reports a case where swelling of the right half the tongue had recurred periodically for a period of two years. With each attack pus would be extruded from a sinus in midline in front of the lingual V. Recovery would follow in a few days. Finally, during an attack, a long deep incision over the swelling and pack in the wound resulted in perma- nent cure. Demarquay cites two cases (of Blandin and Cousin) where diagno- sis of cyst was held until incision proved the real condition. Where both sides of the tongue are involved the treatment is esentially the same. Incisions along the dorsum of the tongue — one on each side 1.5 cm. from the median raphe about 2 cm. long and 1 cm. deep — should be employed. Unless the ranine vessels are injured there is little danger of hemorrhage. Free bleeding which usually follows is helpful. Relief is usually prompt, though the normal size of the tongue may not be regained for some time. When there is localized hardness or ab- scess puncture may be made as in any abscess, over the localizing point. The invisions mentioned may seem large when first made. It is surprising how small the incisions appear when the swelling has gone from the tongue. The wounds close quickly, heal rapidly, leaving shortly, merely a faint linear scar which in no way interferes with movements of the tongue or with speech. When gangrene has set in, incise pos- terior to the gangrenous areas to allow the swelling to reduce. Relieve pressure upon the tongue by placing a wedge between the teeth or extracting the ap- posing teeth. Keep the tongue very clean by frequent washings. Butlin rec- ommends for more vigorous treatment the application of 1:1000 perchloride of mercury, or pure carbolic rubbed in and afterwards washed away. Iodoform powder may be dusted upon gangrenous sores. Care must be exercised that material and sloughs are not swallowed or allowed to run down the throat, as these are prone to cause autointoxica- tion, intestinal upsets or septic pneu- monia. Occasionally involvement is so deep and so near the root of the tongue that the abscess is hardly accessible through the mouth. In such a case, as in one reported by Hahn, the incision and drainage must be made through the suprahyoid region. If suppuration oc- curs in the related lymph nodes they are also to be drained. The constitutional symptoms may be improved by giving small doses of qui- nine and trychnine. Where pain is se- vere moderate doses of morphia may be used. July, 1922 ORIGINAL COMMUNICATIONS 359 Prognosis — While all cases are se- portion anterior to the lingual V. rious, the prognosis is as a rule favor- 3. Where only one-half the tongue is able. In hemiglossitis recovery is al- involved there is usually to be found a most invariable. Where both sides are localized tumor tending to abscess for- involved in a purely oedematous or sup- mation. purative process recovery is usual. In 4. While the symptoms are often cases complicated by gangrene progno- alarming, and the prognosis to be sis is poor, recovery depending almost guarded, the tendency is usually to re- directly upon the resistance of the pa- covery regardless of the treatment, tient. 5, The best treatment consists of lib- In a study of 145 cases, Bennett found eral incisions, oral hygiene, purgation, record of four deaths (about 3 per and constitutional support, cent). Of these one died during a de- Case Reports. bauched state; one of suffocation; one observation I-Courtesy of Dr. T. R. of paralysis of the palate, rupture of ^^^^^^^ abscess, hemorrhage and collapse; one ^ ^' 3^ Admitted to the following tracheotomy In reviewing a ^ j^^^ , Hospital, March 26, 1920. scries ot 32 uncollected cases appearing p ^ n.-Negative except several at- in available literature since 1910 there ^^^^^ .^ tonsilitis. was only one death. This was in a case ^ ^ _Sore tongue of gangrenous glossitis, complicated by „" * ^ ,, ^ ' tit„v.»i, 00 iQ9n asi^ration, pneumonia and collapse, the Began last Monday, March 22 1920, report of which is appended. (Case 3). with sore throat. Soreness cleared Tues- ^ , ,/; . ,, day. Returned two days later and tongue In cases where there are frequently ^^^ ^^ ^^^^^^ ^^^^^^ ^^^^ ^^^^^^^ repeated attacks prognosis is good, the ^^f ^^^ ^^^ ^j^^^ ^^^^^ j^ ^^ ^,^. ultimate cure depending upon the ehm- ^^^^^ ^^^^^^ ^^^^^ indentation of ination of the causative factor. Ben- ^^^^^ ^^^^^^ negative. Speech very nett cites a case in which three attacks ^.^^^^^^ ^^ admission the temperature occurred in three years Cure was ^^^^^ ^^^ ^^ ^^^ ^.^^.^ ^.^^^ j^^^^s finally effected by removal of amalgam ^.^^^ ^^ ^^^ ^^ ^ p^^i^^^ ^^^ fillings in some teeth. In another case ^^^^^^^ ^^ jj^ ^^U^^^^ ^^ ^^g^^. there were six attacks Removal of ^ ^^iphate. Potassium permanga- false teeth eliminated the disturbance. ^^^^ ^^^^^.^^ ^.^^^O ^^^ ^^ed as a In long standing cases the danger lies ^.igansing agent and potassium chlorate in end results. Bennett cites a case last- gQi^^ion was used as an astringent ing 90 days in which marked adhesions ^^^^^^^ ^ash. On the following day the formed the tongue and cheek, which g^gHj^g was greatly reduced. The tern- had to be severed and kept free. In only pej-^^m-e returned to 100.3 degrees F. a very few cases where very wide incis- p^j^ ^^^ j^^g marked upon swallowing, ions must be made, or where gangrene p^^-je^t continued to improve. The tem- occurs resulting in actual loss of tissue p^j-^ture dropped on the third day to is there the slightest interference with j^^^j-j^al. Patient was out of bed in five the use of the tongue or speech follow- ^^^^ ' q^ ^^le seventh day was dis- ing convalescence. charged as cured. Conclusions. Observation II— Service of Dr. A. P. 1. Acute parenchymatous glossitis is c. Ashhurt. usually an infectious, inflammatory G. W., male, 46. Admitted to hos- process, but may be a nervous phenom- pital, December 1, 1921. enon. It is frequently accompanied by Past History— Erysipelas on nose suppuration, abscess formation and gan- and face one year ago, at which time grene. was in bed for five weeks. 2. The entire tongue may be involved. Present Illness-November 25 while but usually the swelling involves the eating fish at midday meal, he teit 360 SOUTHERN MEDICINE AND SURGERY July, 1922 scratching on side of tongue. Thinks a bone stuck him. At 3:00 p. m. tongue began to get sore with feel as of some- thing sticking in it. This continued until 11-28-21 at which time a physician was called. A diagnosis of ulcer was made and it was "burned off with some liquid." Gargles were used frequently. The next day the same doctor advised that the man had an abscess of the tongue. November 29th the pain was so severe that he could not sleep. Speech became difficult. On account of the increasing size of the tongue he began gagging and choking. He could almost feel the tongue getting larger and larger. December 1, 1921, he was admitted to our service. On admission the man was in great distress, but apparently not acutely ill. The mouth was partially open, the tongue protruding slightly. Upon ex- amination it was found that the swell- ing, while marked, was limited to the right half of the tongue. At the junction of the middle and posterior thirds a mass 2cm in diameter, tense and yellowish, suggestive of pus, was seen. The floor of the mouth was not involved. The cervical glands were not palpably enlarged. Treatment: Shortly after admission the patient was operated upon by Dr. Ashhurst. Under local cocain anaes- thesia the tip of the tongue was caught with forceps. Incision was made along the right border of the tonguq 4cm long, where the abscess was pointing. 2-3cc creamy greenish pus evacuated. Shortly Calomel gr. II followed by Magnesium Sulphate were given. Dur- ing night patient given M. S. 1/6 gr. The following day improvement was marked. The swelling rapidly subsided. Five days after operation the tongue was very slightly swollen, and as the general condition of the patient was so good, he was discharged as cured. Observation III — Service of Dr. Ash- hurst. W. C. female, 67 years. Admitted December 8, 1921. Family and past history negative. Chief complaint — Swelling of Tongue. Patient states that for some months she has been bothered with bad teeth ; that at times those on the right, es- pecially, have irritated her tongue. Five days ago she felt a little soreness in the left side of her neck. Later in the day the right side was painful and swollen. The following day the tongue began to swell rapidly. Yesterday it became so swollen that she could not talk. It was then that a physician was consulted. He advised her to come to the Hospital. She states that heretofore her general health has been very good. Upon examination the patient was found to be a fairly well preserved female, aged 67. Complexion rather anemic, expression that of distinct dis- tress. Temperature 101'. Respiration 28. Pulse 120. The mouth was open. The tongue was diffusely swollen and very red, covered with a greenish, mucoid and slimy substance, which had no particular odor. The tongue was so swollen that it protruded several centi- metres beyond the teeth. The protrud- ing portion was very dry and hard. Pal- pation was not painful, nor was there any area which was particularly soft or fluctuating. The tongue was scarcely moveable. The speech was almost unintelligible. Swallowing was well nigh impossible. Salvia, blood tinged, constantly dribbled from the mouth. The patient had to sit erect with head forward to breath with any degree of comfort. The floor of the mouth was not involved. The teeth were in very poor condition. There were several sharp stumps, particularly in the lower alveolus. The glands in the submaxil- lary regions on both sides were some- what swollen and hard. There was no cellulitis of the neck. Examination of the chest was unsatisfactory because of the dyspnea. No area of dullness was detected. Physical examination other- wise negative. The general condition appears to be poor, the patient ap- parently being almost exhausted. Treatment: Operated on by Drs. Holloway and Crossan, VA hours after admission. One per cent Novocain ap- plied locally. Incisions made on each July. 1922 ORIGINAL COMMUNICATIONS 361 side of median raphe' 5cm long, 2cm tending from the chin to the upper deep. Incisions made on each lateral border of the sternum and from the margin of the tongue about 1.5cm deep. Trapezius on the left to the posterior A little pus was obtained from site of border of the sternomastoid on the the left lateral incision, greenish and right. No bullae or blisters were pres- fetid. Rubber tissue drains made to ent. Erysipelas was diagnosed. The communicate between dorsal and lateral general condition was much worse. The incisions. Silk suture passed through temperature had risen to 102.4'. Stimu- tip of tongue to hold tongue forward and lants were continued, to facilitate breathing. Several teeth After midday collapse was imminent, were removed by Dr. J. R. Cameron, Diffuse, bubbling roles were heard over D. D. S. to relieve pressure on tongue, the lungs. The temperature dropped to Bleeding was fairly free from incisions 100.2F Rectal. The patient was con- in tongue except on left lateral side scious but paid little attention to sur- where the cut area remained almost roundings. The temperature rose in the dry. As the patient's condition was very afternoon to 104'F axillary. Further poor, and verging upon collapse it was treatment was without avail. The thought unwise to purge her. Mor- patient died shortly after midnight, phin and Atrophin were given half hour General autopsy was not permitted, prior to operation. Following the Portions of the tongue were removed operation continuous enteroclysis of after death. A specimen from the right glucose and soda was started. Strych- side showed acute suppurative mflam- nin gr. 1/60 hypodermatically q4h and mation, that from the left gangrene, whiskey q4h were ordered. Cultures were not made. Results: On the following day the ^t may be admitted that this case condition was verv poor. The tongue -as too far advanced before receiving was reduced somewhit. especially on the '^uj'gical attention to hope for a success- left half anteriorly. In this region the i,"VT\'^- - „„ ^ , A...4n Par^n color had become darker, paler, and Tabulations of 32 Cases of Acu^^^^ yellowish. It looked as if it were under- jhymatous Glossitis Reported Since gcing mortification. No line of demar- l^^"* cation was detected. The respirations Sex. were less difficult, and the patient was ^^^^-- ^g more comfortable. By 4 p. m. the tem- Xo^^statedJ_- -"-'____'_"-_ _'_.___' 5 perature had dropped to 100; the res- — pirations to 20, the pulse 90. However the exhaustion was more marked. The ^ , . , ' 2i patient was hardly able to endure lying L^'flalf !!"1~---"----------------^ 8 flat in bed even on her side on account r. Half 3 of dyspnea. She was too weak to sit ^ erect or nearly so. Consequently some shortest time recovery noted 24 hours of the secretions and saliva must have Longest time recovery noted 26 days passed down her throat. Swallowing gj- Tl;L^i:^^y:::::::::::::: \l was almost impossible. Dribbling from cases not treated (refused) 1 the mouth continued. ^'''"'^" Death" '"^'^''''^'"^ II" ^i On the following day December 10, ^^^^^ presumabfy neuroti"c'__V__V-V-V-V_- 4 1921, the tongue had subsided consider- ^ ' ably, so much so that it barely protruded Keterences. beyond the teeth. The left half an- Baldwin, W. H., Cincinnati Med. J. 1896,. teriorly was involved in a slough of the "gP-^nett; Wash. Med. Ann. 1906-7 V. p 267. entire thickness of the tongue. Over Butlin: ' Diseases of the Tongue: Cassell the neck anteriorly was noticed an area & /;- l-^,- '5o'n''-A.!"''Xnn. Otholo.v. of redness, sharply defined with slightly Rj,i,;^iogy & Laryng. St. Louis, 1918, XXVII, raised margins, irregularly outlined, ex- 2O6-212 Disc 394-97. 362 SOUTHERN MEDICINE AND SURGERY July, 1922 Duckworth: Liverpool Med. Chi. Jour. 1883 ner we see new signs appearing, not oibney/virginius. J. A. M. A. Chic. 1917, necessarily signs of a commercial LXVIII. 1476. nature, unless medicine be so classed, Duperier These de Paris 1906-7 but the signs of osteopaths, chiroprac- Fiorovanti: II Morgagni, 1914, LVI, p. 274. , j i i i ^ ^-, Gerhard, Sam. H.; Codex Medicus, Phila. ^ors, drugless healers, mechano-therapy, 1896-97, III, 421. and the like. Why this great increase, LXV^p"''333^^'^' ^ ^"''^' ^'P"'"^'' ^^'^^- ^^^^' is it the fault of the regular physician Hill, Berkley; Brit. Med. J., October 7, 1882 or the public? P- 683. . In the writer's opinion, the public to Svp.t?. Othologia. 1914 Vol. ^ ^^^^^ ^^^^^^ ^^^ ^^ ^^^^^^ ^^^ ^^^ Lubman, Max, N. Y. Med. J. 1916 CIV, 1146. physicians must assume a part of it. Lewis, Robt. N. Y. Med. J. Oct. 9, 1897, Three fourths of the illness of today ^'Loeb, Virgil: Dental Summary, Toledo, is of a functional nature. People do not 1910 XXV p. 668-673. necessarily imagine it, but they certain- BroS^Phila^fssT ""^ ^^^^""^' "' ^^^- ^"^ ly do magnify their conditions out of all Prenn, Joseph; Boston Med. & Surg. Jour- proportions as the true state of suffer- nal, 1916, CLXXIV, 161-163. ing xxvT22S"^ ^''' L^"y"^^^'^P^ ^P''- 1^1^- There can be no question about it; it Ref. Handbk. Med. Sciences (Ed. by T. L. is cases of the above description (func- Stedman) \ym Wood^ N Y., 1917. P- 209 tional) that has put the physician at Stengel & Fox, Pathology; 6 ed., W. B. Saunders Co., Phila., 1919, p. 598. sea as to cause, and unless the true Summers, B. E.; Old Dominion J. M. & S. cause is discovered and removed, if pos "ichmond, 1915-16. XXI p. 75. Thomas: Marseille Med. 1905 XLII Richmond, 1915-16. XXI p. 75. gj^jg^ how can a person be expected to 512-516. return to a normal state? Thibaud: Theses de Paris 1893-94. In trying to discover the cause, and ^^Wagner, Clinton; Med. Record 1893 XLIV incidentally to keep the investigator in White, J. v.; Jour. Mich. State Med. Soc, the limelight, we are being taught that Grand Rapids. Mich., I9i6fi, XV. p. 114-115. a local focus of infection must exist N. B. Since writing this paper Von somewhere. Of course, it is only most N. Mander, Kopenhagen, reports a case natural that each man working in a of edema of the tongue following the different line should locate the focus in intravenous injection of mirion in a his chosen field; thus we have the tabletic patient who had never had any tonsils, teeth, sinuses, abdominal viscera, syphilitic manifestations. Edema in- in fact, not a section of our anatomy has volved tongue and both submaxillary escaped as a possible seat of housed up regions. Recovery followed within two germs, which are sending forth their days, without operation. poison to destroy us. But it is quite evident, if we must be- 192^,' p''29^!'"'''^'' Wachenschieft, 13 March, jj^^^ ^^^^ ^^^ p^^pj^ ^^jj ^^^ ^^^ ^^^^ of our colleagues can give personal tes- timonials, local foci as a cause of every ill to which mankind is subject, has been DISCLOSED BY THE URINE given a pretty fair chance and found wanting. By Dr. J. Henry Dowd, Buffalo, N. Y. Thg^e is no doubt that a local focus Never in the history of medicine has "^^^ ^^ times house pyogenic bacteria it been necessary for the doctors who that are capable of destroying life. Such , . , -t. J. • J.-U u 4. conditions have been met with since Pas- treat humanity to give the very bes ^^^^ discovered bacteria, but when it there is in them, as it is at the present ^^^^ ^^ ^^^ ^^ charging every pain, ache or symptom to such a condition, is it Weeds grow rapidly, but even to the any wonder we are today reading in our casual observer it must be evident that journals about fads, and ridiculing them. irregular practitioners by influence are Speaking of disease, it is becoming increasing in number and at every cor- more apparent every day that there are July, 1922 ORIGINAL COMMUNICATIONS 363 no new disease. There can be little The procedure the writer advances is doubt, disease is as old as the human far from new and cDnsists simply of race, anything we learn that is new making the urine tell us how fully eighty about some particular malady is due to per cent of the individuals presenting the fact that it is a little more graph- themselves at our offices can be relieved ically described. promptly. The above refers, of course, It will be granted that symptomatol- to functional conditions, but the urine ogy of the same ailment may to some will go a step further, and it can be extent differ in different individuals, made to tell us why resolution is slow but the cardinal symptoms are always in organic conditions ; why pain persists present with little or no change. Take, after well-known remedies for its relief for instance, typhoid fever ; the tem- have been given. perature runs the same up and down For normal function in the human course today that it did when that dis- being we must have organs well supplied ease was first investigated and de- with nutrition, and metabolism must be scribed. carried on in a similar nature. Briefly speaking, disease can be di- Nutrition is supplied the different or- v=ded into two classifications: the or- gans through the blood and nervous sys- ganic variety, or those conditions where tem ; in other words, the blood and nerv- there is an underlying anatomical ous system have a food ; hemoglobin for change, with a definite cause, generally the blcod. and phosphorous, lecithin and an infection, new growth, injury or nuclein for the nerve cells, something that produces a change in the A want of hemoglobin, anemia as it tissues. is called, practically always is accom- The symptoms of the different organic panied by a trace of albumin in the troubles are, generally speaking, char- urine, providing we can eliminate in- acteristic. Fever, increase in pulse rate flammation along the urinary tract, gon- in ratio to the temperature; pain, usu- orrhcea, cystitis, pyelitis and Bright's ally localized and stable, being increased disease, on movement or pressure. Poinding such a condition, the artifl- In the second variety, or those of a cial administration of iron (the writer functional nature, there is no anatomical uses Basham's mixture) is quickly fol- change to account for the condition, and lowed by marked improvement in all it ^'s just this variety of illness that baf- symptoms, and if there are no other fles the doctor and has instigated the complications present, complete recov- search for a cause that as yet certainly ery ensues, has not been found. Briefly reported the following case In these conditions the symptomatol- must show the great value of ascertain- ogy is as variable as the minds of the ing the true cause: people that present themselves for treat- Severe headache for which an oculist ment. There is no fever, and if there is, was consulted but could do nothing for it is only trivial in nature, possibly due him. Following meals there was con- to some brief intestinal condition. Pain siderable distress; the bowels were ir- of which most people complain is not, as regular; constipated, varying with a general rule, localized, but transient, looseness at times. There was a general here at present and some place else in feeling of fatigue. Being told that the a few hours. It may be neuralgic in headache was intensified upon use of the nature, and not usually increased by eyes, it seemed that they must be the movement or pressure. offending agent, but the oculist said That there is a cause for the condition, there was absolutely no trouble there, no one will deny, and if we want to con- Estimation of the urine showed no tinue in the patient's good graces, for sugar, casts, pus or blood. Indican in- they are the ones that talk, and talk of creased and phosphatic index normal ; the failure of doctors, it behooves us ti there was a trace of albumin. Mist, discover the cause and rectify the same Ferri et ammo. acet. two teasnoonfuls in every case if possible. in water after meals relieved the head- 364 SOUTHERN MEDICINE AND SURGERY July, 192i ache in three days, all other symptoms vanished in a week, reading caused no further trouble. Metabolism, in simple language; chemical systemic combustion, when not normal is called defective metabolism, and is an important factor in various systemic ailments. Thus we may find albumin, casts, in- creased indican or uric acid, and uro- resin, sugar and free crystals of uric, oxalic or the coffin lid variety of phos- phates. As an example: C. F., young mar- ried farmer, had always lived in the open, until inheriting money when he moved to the city and commenced a life of idleness. Being possessed of a good appetite, he simply gormandized until driven to consult the writer for indiges- tive symptoms occurring after each meal. Summed up, the symptoms were, "I don't know exactly where I feel bad, for I feel bad all over." A careful examination (urinary) re- vealed a trace of albumin with casts. hyaline and epithelial; the epithelium did not show degeneration indicating a true Bright's disease. Great increase of indican and uroresin, as occasional free crystal of uric acid ; the phosphatic in- dex was normal. It was very evident that there was no pathological condition present, merely a functional one, but of course, if allowed to continue would end in a change in the kidney structure. The diet was cut to the simplest kind of food, exercise was advised, prefer- ably a return to the farm, and a mixture of sodium salicylate, gr. 5, caroid, gr. 1, in water after meals. There was no albumin or casts in a week's time, indi- can disappeared with the free crystals; he reported he felt perfectly well in two weeks. The urine of T. F. was sent the writer for examination with the message, "I do not feel well." Examination showed specific gravity 1026, acid, no albumin or casts, great increase of indican, no pus, free crystals or oxalates and sugar ; the phosphatic index was AO^/, plus. It was impossible to get a further history, other than that the man had been feel- ing ill for several weeks, had consulted a doctor, but had received no benefit and dispensed with him. In these cases of glycosuria, it is impossible to say at once whether they are organic or merely functional and due to non-oxidization or defective metabolism. A strictly carbo- hydrate free diet was ordered and bro- mararum (bromide of gold and arsenic) prescribed with orders to send another sample in ten days. At this time the sugar had decreased about 75*;; ; word was sent the man was greatly improved. Being unadvisable to continue a free carbohydrate diet too long, a baked po- tato and two slices of toast were added to his menu ; asking for another sample of urine to be brought in about two weeks. At this time there was no sugar ; indican, and uroresin were normal in amount and index 10'; minus; he re- ported he felt fine. The same medicine was continued, adding to the diet bread and other carbohydrates. Sugar has not again appeared, although for months he has been on a full diet ; the man may be considered as well. Every action, word, deed, thought; every organ in the body receives its im- petus from the brain. The brain has a specific nutrition which it gets from the food taken by the mouth and by a pro- cess of digestion, assimilation and meta- bolism is converted into phosphorus, lecithin and nuclein, the food of the brain cells. In the absorption of nerve cell nutri- tion, not only sufficient is taken for the normal daily calls for energy, but enough to create a reserve which may be stored to be used in cases of emer- gency, when, from any cause, food can- not be taken by the mouth in sufficient quantities to supply the normal calls. When this nutrition has performed its function, the residue or waste is cast off in the form of phosphates and is found in the urine. Two varieties of phosphates are found: the calcium and magnesium, or earthy phosphates which appear in freshly passed urine, or on boiling. These have no clinical signifi- cance and may be dropped from further consideration. The other variety, the alkaline or sodium and potassium phos- phates are never seen except after pre- cipitation with an alkaline solution July, 1922 ORIGINAL COMMUNICATIONS 365 (mag. sulphate, ammo, chlor., aq. ammo, should be a routine in all cases, medical 10'^ of each an ounce, water 8 ounces) . or surgical, it gives more information They appear as crystals, fern-like in ap- than any other test we have so far." pearance ; this variety show nerve cell 437 Franklin Street. metabolism. Taking the phosphatic index is a sim- pie procedure, using the second urine THE LEGAL PHASE OF THE PROB- passed m the morning. Fill phosphato- lem qF FEEBLE-MINDED- meter with urine to U, add sol. to S, NESS* shake thoroughly and set aside for ten « t ^ t • , A il-i • -4. i. 1. ij By J. C. Lamer, Attorney. mmutes. A white precipitate should form at once and sink according to the ^^- Chairman, Ladies and Gentlemen: amount present and the specific gravity ^ deem it an honor to the legal pro- of the crystals. If it registers practi- Session which I represent that you have cally solid at NP, the nervous system given one of its members a place on your may be eliminated as a factor in any Program today on the occasion of the case under treatment. If it remains Memorial and Dedication exercises of above NP, in a solid mass, irritation or this great and good institution that you hypersensibilitv of the neurones is in have just inspected, and I feel keenly evidence and sedatives should be given ; ^y responsibility in presenting to you the bromides and valerian, if the case is at this time the attitude of the legal fra- acute ; the bromide of gold and arsenic, ternity towards the great problem of if it is chronic, as in high blood pres- insanity and feeble-mmdedness, and its sure, which is generallv an accompani- Phases in relation to us and to the courts ment of a plus index. Where it does not of our land. sink, is light and fluffv. or goes below ^"^r this problem is a problem that NP, we have a condition similar to a concerns us who seek the administration want of hemoglobin; there is a want ^^ justice no less than it concerns the of nutrition, which must be supplied ar- mec^ical profession that seeks to cure tificially before normal action will be ^^^ eradicate disease and affliction, forthcoming in either flesh or bone. There is no lawyer worthy of his pro- To recapitulate • fession who has not seen and recognized Fully three-quarters of the cases that ^"d regretted miscarriages of justice, consult the practitioners of medicine are ^'^^n some person of feeble mind or dis- suffering merely from some functional eased brain has been haled into the condition; it mav be due to a want of courts and sentenced without ceremony hemoglobin, as is found in anemia; a to the roads, or perchance to the electric defect in perfect metabolism, or to a chair, instead of being placed under the want of nerve cell nutrition. These are care of a physician, or placed m an in- cases that bother the medical man, in- stitution such as the Caswell Training asmuch as thev present a variety of School, or a kindred place. To those who symptoms very hard to classifv. and still know and understand penology, msan- harder to relieve, because the true cause ^tv, and feeble-mindedness, such cases must be discovered and this is not done ^re horrible blunders, for which they are in the great majority of cases. P^one to blame the lawyers and the Scores of cases could be reported courts of justice, where, after weeks of treatment with But what can the lawyer, or the judge little or no tendency toward recovery, do? There is no law school within my the taking of the" phosphatic index knowledge that includes m its curricu- showed at once the true cause to be '""^ ^ course of instruction on such sub- either a hypersensibility of the neurones -iects as I have just mentioned. There or a want of nutrition. Prescribing for has been no point of contact established these conditions as the index indicated, between the science of the law and that recovery was almost immed'ate. " , ,, . , „ , ^ ,. T», f^^t- T\ r^u n 11. o -i-u * Read at the Memorial Exercises and Deui- In fact, Dr. Chauncey Pelton Smith ^^^^^^ ^f j^-ew Buildings at the Casweii Train- says, "Taking the phosphatic index ing School, Kinston, n. c, April 13-14, 1922. 366 SOUTHERN MEDICINE AND SURGERY July, 1922 of medicine, to the end that courts might and the chemist, working hand in hand fairly and intelligently deal with such towards the common good. And what cases. Therefore, until such contact is has been done by these two sciences can made, until there is a closer co-opera- be done equally well by co-ordinating the tion between the great professions of sciences of law and medicine. But the law and medicine, we lawyers can only fault has been that although you of the blunder along, until the knowledge ac- medical profession have gone far in your quired by the doctor shall become the search for the causes that make of a common property of the lawyer. We man a criminal, your knowledge thus sometimes dream of the time when jus- gained has not been disseminated among t'ce will come from the exact relation of the advocates of the law, has not been all the facts to every case, but until placed at their command, and conse- medicine gives us the knowledge to bring quently has not been applied to the ad- out the facts and apply them, the farce ministration of justice in the courts of and injustice of trying a mental incom- our land. You doctors have applied the petent in a court if law must still pre- knowledge of the chemist to your pro- vail, fession, but your knowledge concerning But the time has arrived when it will feeble-mindedness and insanity has not not suffice for the medical profession to been applied by our profession. I can- hold up its hands and sanctifiedly say, not say where the fault lies, but it will "Forgive them, they know not what they be sufficient if we all work with the do," when through the processes of the common aim of correcting it. courts some unfortunate is committed to The administration of the law is a durance vile for a crime committed be- complex problem, because we have to cause of tendencies over which he had apply certain broad rules to all cases, no control. The time has come when And cases differ so much in detail and there must be co-operation between us the elements that enter into it. There to correct and prevent such monstrosi- was never a more misleading axiom than ties of justice. And to do this, the physi- that one which says that "All men are cians, the experts, must teach us, must created equal." Were this so, the ad- show us, and co-operate with us. A ministration of justice would be greatly point of contact must be established. simplified, because, figuratively speak- And this is not impossible. The sci- jng, all could be fed out of the same ence of chemistry is in a great degree spoon. But we know that men are not responsible f#r the modern practice of created equal. We know that some men medicine, and yet it was many years be- are endowed with a great degree of men- fore the medical profession adopted the tal responsibility, while others are born discoveries worked out by chemists in without any, and others with but a slight their laboratories. For instance, mag- degree of responsibility. We know that nesium sulphate was known to chemists there are persons to whom to steal is in 1694, but over two hundred years as natural as to eat. They are born with elapsed before it was learned that it that proclivity, and are powerless to would give great relief to lock-jaw and resist it. And yet, under the law, all burns. Ether was discovered in the 13th men are created equal, and when such century, but its value as an anaesthetic persons are brought to the bar for trial was not recognized until 1846. The for breaking the laws of society, unless chemists have been enabled to isolate they are plainly and notoriously idiots, and eliminate the more poisonous ele- the law takes scant notice of hereditary ments of the drug cocaine, and the adop- traits, or habits growing out of environ- tion of their work by the physicians has ment, and proceeds to apply the doctrine resulted in great benefits. Amyl nitrite ^^at before the eyes of the courts, "all was discovered by a French chemist m , , ^ „ ^x j. ^ ■ 1844, but it was not until 1867 that doc- "^^" ^''^ ^^^^^^^ ^^"^^- ^^"^^^ '^^^- tors began to use it for angina pectoris, sponsibility, feeble-mindedness, as yet Scurvy and beri-beri have been conquer- plays a small part, a very small part, in ed by the combined efforts of the doctor the workings of our system of courts. July, 1922 SOUTHERN MEDICINE AND SURGERY 367 And why is this so? It is not because him into the courts and ultimately to a lawyers and judges are less humane than penal institution. Thus it is that the physicians, but it is because they do not lawyer and the judge are vitally inter- knew how to distinguish the wilful crim- ested in the detection of the mentally inal from the kleptomaniac, the moron, deficienct early in life, before he has had the insane, or the feeble-minded. And the opportunity to learn to prey upon until some organized effort is made from society. But unless there is some sys- some quarter to teach them to make such tem of detection during the youthful pe- distinctions, UBtil every court shall have riod, such a type, once grown, becomes the services of an expert to examine hard to recognize and a burden to the every criminal that comes before it to courts. He becomes wary and ingeni- ascertain whether he is a criminal by ous, and perhaps lives a life of crime for choice of a free will, or because of some some considerable period of time be- defect of the mental processes that na- fore he is finally apprehended and ture has provided him with, no distinc- brought to trial as an ordinary criminal, tions will be made. Such a case might well have been res- And the problem is a difficult one, for cued and saved before reaching man- the reason that it is not the stupid idiot, hood, but when he becomes an adult he but the high grade defective, or the is as helpless to save himself as a ship moron that the courts have to deal with without a rudder, and cannot steer any as a general rule. Such a class is more other course than the one that the work- dangerous than the idiot, 'because he ings of his warped and diseased mind oftentimes belies his appearance. He may indicate. has initiative, and is often not suspected Such a case is as undeserving of pun- of being mentally incompetent, even ishment as the man who shoots his after the commitment of his crime. He friend by accident, and yet what can the does not reveal his weakness by low courts do when he comes before them brows, or furtive looks, or vicious ap- for the violation of the law? Until fa- pearance, but on the contrary is amia- cilities are provided for determining ble, bright, good-tempered, and even their responsibility the magistrates of likeable. To solve the problem of this the law can only deal out their justice class of unfortunates is one that can well measured by the scales of justice as occupy the minds of the best of both the handed down and wrought out by the doctors and the lawyers. experiences of past centuries. And the lawyer is not only interested you know, the purposes of punish- in this class of defectives, but in all j^g^t as administered by the law are classes. He is mterested in not only rec- four-fold, according to theory. It is ognizing and segregatmg them after ^jgj^eji ^^ the culprit in retaliation for they have fallen mto the clutches of the ^he wrong that he has done society, law, but he is interested in keeping them ^hen again, it is administered as a out of the court houses and jails. To earning to others of what to expect if say that a lawyer is not interested in ^-^ey commit similar crimes. Also, it is such a proposition is on a par with ar- administered to prevent the same per- suing that a doctor is not interested in g^^ f^,Q^ committing other crimes preventing disease, but only in curing it against society. And finally, punish- after it has been contracted. It is con- ,^e,-,t is administered in the hope of re- ceded that during the youth of a per- forming the subject. How useless, how son, certain traits will be outstanding futile, are the punishments meted out to that would reveal to expert eyes the de- ^he mentally incompetent by the courts, feet, so that it could be dealt with, and ^^en judged in the light of these pur- if no cure could be effected, then the poses.' And the lawyer and the judge person could be committed to an insti- ^.j^ ^^ ^^^ ^^st ones to correct this fault tution and thus save society of his men- , «.. • ^ i i j • i j • ace. But once let him reach manhood ^'^en sufficient knowledge is placed m unobserved, and these apparent defects their hands to enable them to see the are concealed, and his tendencies lead light. 368 SOUTHERN MEDICINE AND SURGERY July, 1922 If such cases could be only reached give a clue to the mentally weak child, and cared for before they get into court, And when these steps have been two-thirds of the jails would be empty, taken, a public sentiment must be engen- and crime decreased immeasurably. And dered that will demand that the state how can this be done? How can this provide sufficient institutions to ade- issue be met fairly and squarely, and quately care for such cases, so that those how can society protect itself without capable of treatment can receive every cluttering its jails and penitentiaries care towards bringing them back to nor- with such persons? How can they be malcy, and into the folds gf good citizen- kept out of the court house, and trans- ship. And as for those cases that can- ferred to the houses of correction, the not be cured, there must be provided reformatories, or such institutions as places where they can live out their span the Caswell Training School ? How can of life as best they may, in the best en- the courts be relieved of this evil that vironment possible, with no chance for begets so much injustice, even though reproduction, protected from them- administered in good faith aiming at selves, and protecting society from the the common good? potential menace of their presence. It can only be done by a system of ex- And in the case of those who have at- pert examination throughout the schools tained manhood and have begun to prey of the state, where defectives can be upon society and have been caught in early recognized and isolated, and then the act, it is the duty of the state to place patiently watched and wisely studied, to at the command of the courts expert the end that a cure might be effected, or medical knowledge, so that in every case proper steps may be taken to care for it can be determined whether a criminal them properly without menacing society is mentally incompetent before he is by giving them freedom, and without sentenced, so that he might be sent to filling the jails with them after they a hospital instead of a jail, if his case have done their mischief. should so demand. Insanity and feeble-mindedness sire To do these things, to provide early on the increase in all parts of the world, examination for all children for the pur- and steps must be taken to meet this pose of picking out the mentally inferior condition. And it can be met in this ones, to provide suitable institutions for way: By examination and detection their proper care and custody, and to early in life, by segregation and by provide the courts with proper medical reformation if possible ; by prevention knowledge to intelligently act in dealing of the reproduction of their kind; and with suspected mental defectives, will by expert medical examination of those cost the state money, but such a system cases which have managed to come by eliminating the product of mental ir- within the province of the criminal responsibility will more than pay for it- courts, self by the reduction of the population As for early examination and detec- of prisons, county homes, reformatories, tion, family physicians should be re- hospitals, penitentiaries and similar in- quired to make reports of suspected stitutions. It will more than pay for it- cases, which cases should then be passed self, and by ridding society to a large on by a commission that possesses the extent of its feeble-minded population, special knowledge to intelligently mete it will simplify and reduce our problems out adequate remedy in justice to the of pauperism, prostitution, disease, suspect as well as to society. From this, drunkenness, debauchery and crime, it is only a short step to having tests And it will carry us one step nearer the inaugurated in the schools to check up millenium and aid our professions to on the work that has gone before, where reach out towards the goal, where jus- teachers could report cases of inability tice will be measured in golden scales to to learn, persistent misconduct, or other all as they deserve in the eyes of their abnormal tendencies. All teachers Maker. should be taught and instructed to apply With this end in view, let us, both the such simple tests as would most likely lawyers and the doctors, press onward, July. 1925 ORIGINAL COMMUNICATIONS 88» and by co-operation and zeal, attack this easy task and often calls for all of ones great problem sanely, intelligently, re- diagnostic skill. There is no one clinical lentlessly, until we stamp out in great examination or laboratory help that can measure, and wholly control, this blot be used to the exclusion of all other on our civilization, and this scourge on methods of sinus examination, the justice of our courts. It is not unusual for a casual inspec- THE SIGNIFICANCE OF NASAL POLYPS.* H. C. Shirley, M. D., Charlotte, N. C. While the subject of this paper is, "The Significance of Nasal Polyps," it is my intention to present to this section the work that is being done in our cilinc in regard to the cause and cure of nasal polyps. Our observations have led us to believe that we are all prone to treat this condition as a disease per se and to allow our patients to consider it as such. We are all too familiar with the patient who walks into the office and announces that he has returned for the removal of his polyps, adding the statement that this has been done at intervals for years. The clinical picture presented by the patient with this condition varies wide- ly. He may be, apparently, in perfect health, but most often he will be anae- mic and under-nourished, will frequently present chronic pulmonary changes, and last but not least, is pathetically nervous and irrtable. It is not unusual for patients of this type to faint when the slightest examination is attempted. This state of affairs is not due to the changes in the nasal mucous membrance which has undergone polypoid degeneration, but it is a systemic reaction to chronic infection. We believe that, with the exception of polypoid hyperthrophy of the posterior end of the inferior turbi- nates, the presence of nasal polyps means infection, and this infection is regularly found in the accessory nasal sinuses. Our next step in the treatment of a patient of this type is the process of picking out the sinus or group of sinuses involved. This is not always an 1. Left autruni filled with polyps. tion of the nose to fail to reveal the pres- ence of polyps at all. No less an au- thority than St. Clair Thomas says, "Mistakes made are probably more fre- quent than in any other of the ordinary affections of the nose and are only equalled by the frequency with which polyps are overlooked." (Page 230). No examination, therefore, of the nose is complete until the nasal mucus mem- •Rcad lit'fitrt' I he Winston-SaliMU niiMMhig of Uio North (laroli.ui AhMli.al Society, April ^ ^^^^ ^^^^.^^^^ ^^U^^ ^i^h polyps. 25-27, 1922. ethmoids are clear, The 870 SOUTHERN MEDICINE AND SURGERY July, 1922 brane is shrunk and the entire nasal cavity is carefully inspected. This, of course, includes inspection of the region of the posterior sinus orifices, which is now satisfactorily done with the electric nasopharyngoscope. Polyps may often be demonstrated by cocainizing the an- terior end of the middle turbinate and gently lifting it up, and examining be- neath it with the probe. of sinusese, viz., the anterior ethmoids, frontal, and anthum of High ^^' ore, are situated. Polyps, therefore, in this re- gion, indicate a chronic infection in one or all of the group of sinuses just men- tioned ; and in our experience the antrum has proved to be the sinus most commonly infected. If this focus is not removed the polyps promptly recur in the nose. In diagnosing polyps in the k^ 3. Both autra polyps. ind both ethmoids contain 5. Both dense. autra and both ethmoids very Now as to the situation of the polyps, antrum the X-ray is an invaluable aid They will- most frequently be found ^nd has revealed their presence when springing from beneath the anterior end the antrum was perfectly clear on tran- of the middle turbinate. It is here that sillumination and gave essentially nega- the natural orifices of the anterior group ^ive findings on irrigation. 4. All of the sinuses on the right are filled with polyps. Pausinusites. July, 1922 ORIGINAL COMMUNICATIONS 371 The second most common, and sur- pending on a relative or an absolute de- prisingly frequent, situation of polyps is nciency of iodin. No accomplishment in the olfactory cleft and about the in preventive medicine has a tirmer posterior end of the middle turbinate, physiologic and chemical foundation Since the posterior ethmoids and than that underlying goiter prevention, sphenoids drain above the posterior end As the work of preventing is based on of the middle turbinate, polyps in this certain of these tacts, the more import- region indicate infection in this pos- ant are reviewed by the authors. A terior group of sinuses. milligi'am of iodin, given at weekly iii- Gentlemen, I hope I have indicated, tervals, has been found sufficient to pre- with more or less clearness, the views vent thyroid hyperplasia in pups. If held in our group, in regard to the cause the iodin store in the thyroid is main- and cure of nasal polyps. Let me reiter- tained above 0.1 per cent, no hyperplas- ate, we believe nasal polypi are the tic changes, and therefore no goiter, can result of sinus infection and that they develop. The method as applied to man can only be permanently cured once and consists in the administration of 2 gm. for all, when the sinus disease is era- of sodium iodid in 0.2 gm. doses, dis- dicated. The result of this method of tributed over a period of two weeks, and treatment is proving high satisfac- repeated each autumn and spring. This tory in our hands. We have followed it amount of iodin is excessive, and far for almost a year now, and thus far we beyond the needs of the individual or have not had a single untoward result of the ability of the thyroid to utilize and have not had a recurrence of the ^j^^j g^ore it. One gram distributed over polyps in a single ca.se. I have brought ^ longer period would be better. The along a few X-ray pictures of selected ^^^m or mode of administration of iodin cases that will help illustrate the differ- jg ^^ li^-^lg consequence. The important ent types of sinus infection in which we ^^j^^g jg ^^at iodin for thyroid effects have used this method of treatment. g^ould be given in exceedingly small amounts, and it is believed that most of the untoward effects recorded are due Prevention of Simple Goiter in Man. ^^ ^j^g excessive doses employed, or. The ultimate cause of simple goiter more concretely, to the abuse of iodin. is totally unknown, notwithstanding a The results of their two and one-halt relatively large amount of study. The years' observations on school girls in immediate cause is a lack of iodin. The Akron are as follows: Of 2,190 pupils enlargement, therefore, is a symptom taking 2 gm. of sodium lodid twice increases the ioain needs of the organ- yearly, only five have developed enlarge- ism, as in certain types of infection, or ment of the thyroid; while of 2 305 pu- and may result from any factor which pils not taking the prophylactic, 495 which interferes with the normal utili- have developed thyroid enlargement, zation of iodin; or it may result from Of 1,182 pupils with thyroid enlarge- actual experimental deprivation of ment at the first examination who took iodin. After consideration of all the va- the prophylactic, '^'(^ /hyroids have de- rious substances, agents and theories creased in size; while of 1048 pupils that have been put forward as having a with thyroid enlargement at the first role in the etiology of goiter, David Ma- examination who did not take the pro- r^e New York and 0. P. Kimball, phylactic, 145 thyroids have decreased Cleveland (Journal A. M. A., Oct. 1, in size. These ^^^'''^Z'ZlltVZ 1921) state that at present we must a striking manner both the pieventive fall b;ck on the view that thyroid hy- and the curative effects. The d /« perplasia (goiter) is a compensatory re- of giving lodm, m the amounts indicat- action arising \n the course of a meta- ed. to children and adolescents are neg- hoUc disturbance and immediately de- ligible. Charlotte Medical Journal Company S72 SOUTHERN MEDICINE AND SURGERY July, 1922 CAiiTUTDKi urniriMC A Kin ciTDrcDV Analogy aside, how may we candidly JUUIMtKW ffltUllllNt AWU iUKbtKl inquire into the merits of each side Published Monthly by the and arrive at a just and wise decision? First, by considering the opinions of men who have spent their lives in medi- M. L TOWNSEND, M. D. {_ cal education. No attempt will be made /. c. MONTGOMERY, M. D. \ ' '"'® ^o quote from the various leaders in this CHARLOTTE. N. c. ^^^^ who were so freely consulted in the recent contest between Charlottesville and Richmond. Suffice to say that the "Read not to contradict and confute, nor to u i • • -j. j? j i.i, i *i. believe and take for granted, nor to find talk overwhelming majority favored the lo-Ti^. and discourse, but to weigh and consider." — cation of a medical college in a city. 7 Francis Bacon. jjgj.g ^^y ^e added the statement that » -~~- philanthropists who have set aside great ON LOCATING THE MEDICAL sums for the furtherance of education along all lines, including medicine, have, SCHOOL OF THE UNIVERSITY. through agencies duly constituted, North Carolina's great need of a full placed themselves on record as opposed course leading to the degree of Doctor to the idea of teaching medicine in a of Medicine is admitted. The cap stone small town. The American Medical As- of our educational system — the Univer- sociation has taken the same stand and sity — the public at large and the medical never wavered in its allegiance to the profession are agreed. The next point idea. to be decided is that of location. Ap- So far we have had only opinions; parently the case is one of University those of persons and groups entitled to Village vs. City. Many will immediate- respect it is true; but it is too much to ly ask : What city ? The answer is : ask of intelligent men, that they accept The city offering the most advantages; opinions from sources however exalted, but certainly a city. without some setting forth of reasons. Virginia has recently gone through These are not far to seek. Those appli- the throes, of a great struggle to decide cable to the case of Virginia, we find to for herself this important matter. The At the case of North Carolina and with result may be fairly stated as a draw, e^'^n greater force. Let it be remembered though, that Taking up the case for the University many conditions obtained in that case village first: What advantages are which are not repeated here. Our Sister offered ? Much has been said about State had two complete medical schools, "University atmosphere," and all who one in Charlottesville and the other in have had the opportunity to breath that Richmond. atmosphere will agree that it was a Notwithstanding her investment in blessed privilege. But men entering on staff, hospitals, laboratories and lecture the study of medicine have had this rooms, at Charlottesville, and the price- privilege and many of us think it would less legacy from a hundred years of be of advantage to have them gradually service in turning out doctors, the best acclimated to conditions under which the University town was able to do was they will make their livelihoods. It is to bring the decision to a draw. true, too, that a University functions Is it reasonable to suppose that, with- best when its several parts are in close out these potent reasons, and in an even communion ; and that some equipment smaller town, with most inadequate can be used for classes in different col- railway facilities, she would have been leges. But there is a qualifying phrase, able to sustain her cause against the "other things being equal." Are these arguments of those who believed it other things equal? We think not. wiser to abandon the losing game of The last 2 years in a medical course teaching medicine in a village? are spent almost wholly in the study of July, 1922 EDITORIAL 373 patients, and these patients may be ob- An integral part of this out-patient tained in great number and variety, department is the obstetrical section, covering the field of acute and chronic operated on the same plan as regards diseases, only in a city. It will be ob- the referring to the in-patient depart- jected here that many large clinics are ment of cases which bid fair to be maintained in small places. That is anomalous, very true; but let us inquire what is The industrial population of a me- the nature of these clinics? Are those tropolis will furnish patients for train- who are treated in these clinics the kind ing in emergency surgery of every kind, of patients who could not otherwise And so, where patients are to be had obtain treatment and who are willing to to be treated after this manner, we be used for teaching purposes? And have the possibilities of training in the what is the nature of the diseases which care of the sick after a fashion, which, take men to these distant shrines? with few modifications, can be followed Mostly chronic ; while the general out in any section of the state, family physician's practice is made up of The making of a decision as to when ordinary acute diseases and snub-nosed a patient should be put to bed in home ailments which barely have names or hospital would hinge on the same at all. kind of reasoning of the teacher in It has become axiomatic that a medi- charge of any special section of the out- cal school must have 200 free hospital patient department as would be re- beds under its direct control to be kept quired of the family physician into filled for teaching purposes. The third whom the student is to develop, and fourth years of the medical course It is a natural method of teaching are spent almost entirely in the hospital which involves no violent readjustments either its In-patient or Out-patient de- when the graduate goes out to minister partment. to the sick. The very fact of this Out-patient de- What about the teaching personnel? partment growing out of what was In the faculty now teaching the labora- formerly known as a Free Dispensary is tory and other pre-medical branches the significant. Ordinarily things are fitting- University is richly blessed. Among ly named. Adam transmitted his powers, these are men of international reputa- The Free Dispensary was a place in tion, worthily won. What can we anti- which little was done beyond the giving cipate for the third and fourth years, away of a few cheap drugs with little at- There are two means of obtaining the tempt at diagnosis, records or treatment, services of teachers in clinical medicine ; The Out-patient department of a re- first, the old arrangement by which a spectable hospital is quite a different conspicuous practitioner was given a matter. There real investigation is chair and required to give only a portion made into the condition of the patients, of his time to teaching; second the mod- accurate records are kept and treatment ern idea in practice in a few heavily en- is of the same order as that supplied dowed universities of employing an bed-patients. If, as is frequently the eminent man as whole-time Professor case, it becomes necessary to put one and Head of the Department in several of these out-patients to bed, his record branches. Here it must be remember- goes with him; and when he is able to ed that, even where the necessary pe- be on his feet again, he is directed to cuniary and other attractions can be report at the out-patient department, ofl'ered such men, it is essential to In this manner the interest of the medi- have a great number of Associate Pro- cal attendants is excited, none wishing fessors. Associates, Instructors, and As- to break a link in the chain; accurate, sistants, most of whom are making worth-while, consecutive records are their living practicing medicine in the kept ; patients are benefitted ; and locality, and doing their teaching gratis, students are taught. And, even in large and rich Univer- 374 SOUTHERN MEDICINE AND SURGERY July, 1922 sities, this system is not universally re- WILL A PHYSICIAN BE COMPELLED garded as best. BY LAW TO TREAT ALL PERSONS Neither of these conditions can be REQUESTING IT?- met in a village. Students can not be made doctors competent to deal Northwest Medicine in its March, with the everyday problems of a family 1^22 issue, discusses, editorially a situa- physician without the things which are ^^o" ^^^^^ ^^^^^ ^P ^" ^he State of inseparable from a city and center of Washington since the establishment of population. Teachers make a college. Workmen's Compensation in that state, and clinical teachers can not be attract- ^^^ Supervisor of Industrial Insur- ed to Chapel Hill ^"*^^ announces that under the provi- Acute illnesses- tonsillitis, measles, T""' ^^ ^.^" Industrial Insurance act diphtheria, pneumonia, boils, ^^^.^^ ^^^Y P^Y^^^fri is required to treat any ^^1, „u^ „ iT il u 1 u mjured workman apply mg to him for oak, ghonorrhea, ear-ache, broken bones ,*', . u ■ ^^.juxu- ^ ««^ „u,-i.]K-„+v, ^-u j-4.- T-- u treatment who is protected by this act, and childbirth — are the conditions which , i? , ^i .. ^ 1, -, • „r;^^ „„v, . v^ ^ 4- -p ^u 4-- £ ^v. and a refusal on the part of the physi- will consume most of the time of the . ^ , -i.! ^i ^ -f^ u ^ , , , ^ cian to comply with the request will sub- men to be graduated from the School jg^t him to prosecution." of Medicine which the State of North Should this clause be made valid by Carolina is soon to establish. a legal decision it will be the opening Victims of these diseases are treated wedge which will certainly disrupt the in their own home towns. They will very foundations on which the medical not take a long railway journey even if profession stands. It would introduce a the State will take care of their ex- situation the like of which has never penses after arrival. existed in the history of the healing art. There appear no reasons why the It would introduce a principle so revo- University of North Carolina can not lutionary in character that no self-re- satisfactorily conduct its Medical School specting person would dare to class him- in a city distance from the other depart- self a physician. ments as is done by, for instance. Cor- if this revolutionary idea is being in- nell and the University of Illinois. jected into the practice of medicine in Among the many and compelling the State of Washington it is high time reasons against a village location are : that the medical profession of the 1. The impossibility of obtaining United States and the world should be hospital patients for teaching purposes informed. in sufficient number and covering the It seems incredible that such class proper range. legislation could have progressed thus 2. The impossibility of conducting a far in any democratic commonwealth large Out-patient department in which and we do not believe such a law will students would see cases of the kind be sustained in any courts. With the and under the same conditions as in law fixing the physicians fee and the their offices in subsequent practice. law compelling the physician to attend 3. The necessarily worefully inade- all who apply to him, the physician's quate obsterical service. pathway would indeed be an unenviable 4. The tremendous difficulties in the one. To be sure this is not as yet an way of obtaining clinical teachers. actuality— but with such a situation de- 5. The inaccessability of the hos- veloping it is now the time to carefully pital to citizens of the state in need of note the tendency and prepare ourselves treatment. for self defense. July, 1922 EDITORIAL 375 BEGIN NEW WORK AT REX HOSPITAL. Sadie Williamson Children's Ward and New Operating Rooms to Be Added. With the appointment of a building committee and the selection of a sub- committee to carry out the details, the trustees of Rex Hospital have arranged to begin work immediately on the child- ren's ward and the new operating room. The children's department will occu- py the floor formerly used for the oper- ating service and the new oper- ating rooms will be built above on the second floor connected by a corridor to the main building. The children's ward will be provided with a separate entrance, having a ter- raced porch in front which will open on the lawn, separated by the cement walk from the main hospital grounds. It will contain private rooms and a public ward accomodating in all about twenty beds. There will also be a detention room for preliminary examination of all patients admitted ; also a rest room for mothers and a diet kitchen where especially pre- pared food can be made under the charge of trained dieticians. The sun porch will be provided with windows which can be closed in winter and opened in the summer, so that the children may be comfortable in all seasons. In front there will be flowers and shrubbery and a fountain. This department, which has been needed in the hospital for a long time, will be one of the best equipped in this part of the country. It has been made possible by the generous gift of W. H. Williamson and will be known as the Sadie Williamson Children's Ward. The new operating department will contain two large operating rooms, occu- pying a space of fifteen by thirty feet and other smaller rooms with entirely new equipment and more room than has been available heretofore. Work will be begun on these additions in two weeks. All of this is the result of the campaign two years ago when over $100,000 was pledged for the hos- pital. The first project was the pur- chase of property and the erection of the Nurses' Home at an expenditure of over $35,000. This has been paid for and the building with its equipment is well worth the price expended. It is one of the most comfortable homes for nurses connected with any hospital. When this was finished, the South wing which had provided rooms for nurses was opened up giving the hospital about fifteen more private rooms. These have been filled from the time they were open- ed, and are comfortable, airy and quiet. The kitchen, also, has been newly equip- ped and altered so as to give more venti- lation and quicker service. The trustees are going ahead with the additions as rapidly as money and the circumstances will permit. Following the completion of the children's ward and the new operating rooms, the sec- ond story of the south wing will be finished, giving about twenty more rooms for the use of private patients. This will relieve the tension on the ward and provide more room for that class of patients. All of the subscriptions made in the campaign are now overdue in full and the trustees are urging upon those who have subscribed to complete their payments in order that this bene- ficial work may go forward. SURGERY A. E. Baker, M. D., Dept. Editor TREATMENT OF CONVULSIONS OF GENUINE ELILEPSY BY OPERA- TIVE- REMOVAL OF SUPRARE NAL SUBSTANCE (BRUNING OP- ERATION). Karoly Borszeky, Orovsi hetil. Budapest, April 2, 1922. In judging the results obtained it must be made clear that the operation does not effect the epilepsy itself, but only the convulsions, which are the most unpleasant symptoms for the patient. The operation should, therefore, be per- formed only in cases where there are severe attacks of convulsions. Borszeky operated on 9 cases. He removed 3 to 8.5 gm. suprarenal substance, which 376 SOUTHERN MEDICINE AND SURGERY July, 1922 showed no special histologic changes. In later he gave luminal for three or four the patient in whom the organ was re- weeks. In view of the fact that in these moved had the greatest weight, the op- cases the neurologist is completely help- eration showed the best result, but in less, this operation which, though se- the second heaviest suprarenal body re- vere, is not dangerous, is justified. So moved, the results of the operation were far all patients with severe genuine epi- not satisfactory. From these findings lepsy have been operated upon, but with no parallel can be drawn between the careful clinical examination and obser- results of operation and the weight of vation, it may become possible to select the suprarenal body. All of the nine cases where the internal secretion of the patients had suflFered for years from suprarenal body is the chief factor in the genuine epilepsy, and no method of production of the convulsions. treatment had been effective. The at- • tacks were so severe, and followed one tjje PRESENT STATUS OF ANAES- another so rapidly, that the patients tHESIA AS A SPECIALTY. were absolutely incapable of working. The patients were aged from 15 to 51 Joseph e. Lumbard. Am. j. surg., April, 1922. years. The author thinks that only pa- The results of a questionnaire sent tients over 30 years of age should be between 200 and 300 specialists in anaes- operated upon. Bruning at first recom- thesia form the basis of this paper. The mended transperitoneal removal of the average length of time of practice in the suprarenal body, but as this method specialty was found to be about ten proved too difficult, Kuttner recom- years and the average number of anaes- mended the extraperitoneal route, re- thetics given was over 9,000. Most of secting the twelfth rib. From experi- the anaesthetists have hospital appoint- ence on the cadaver it appears that this ments and instruct either students or method is satisfactory. In the first case nurses. All reported membership in Borszeky resected the twelfth rib at some society of anaesthetists. Ether once ; but after he became convinced that was the anaesthetic most often used and the rib resection is necessary only in ethyl chlorid the least often, the former cases with a long thorax, and where the being given generally by the open suprarenal is located high above the up- method. About 50':,', of the specialists per pole of the kidney, he resected the using nitrous oxid find it necessary to rib in only one case. He also removed add ether to the nitrous-oxid-oxygen the left suprarenal. In all the cases the mixture. Chloroform was rarely used, operations were uneventful and there Most patients were examined, either di- were no deaths. He kept the patients rectly by the anaesthetists or indirectly under observation for some time. In by some one else before the operation, none of the cases did the attacks stop Many use preliminary medication. Sev- f ully and permanently. One patient enty-one reported no anaesthetic deaths, died eight and one-half months after the but there were 11 deaths with chloro- operation. This patient had been inca- form when adrenalin was used. Expos- pable of working for years ; but after his ure in some form was considered the discharge the attacks decreased so strik- most common cause of postoperative ingly in severity and frequency that he pneumonia. W. E. Handley in an article could work. In the second case the im- on General Anaesthesia, April, 1922, provement lasted only a short time ; states that the use of chloroform as the soon afterward it became as bad as it anaesthetic for major operation is no had been before the operation; in the longer justifiable. For minor operations, other cases the condition improved ; the also, the use of chloroform should cease, attacks decreasing in frequency and se- The maintenance of the anaesthesia verity. The author found that the at- under ether should vary in depth accord- tacks improved only gradually after the [ng to the needs of the patient in differ- operation, and that they were not, as gnt stages of the operation. Manipula- Bruning says, stopped at once. At first tions of structures richly supplied with he gave no drugs after the operation, but sympathetic nerves requires a deeper de- i July, 1922 EDITORIAL Mental and Nervous James K. Hall, M. D., Dept. Editor Urology A. J. Crowell, M. D., Dept. Editor gree of anaesthesia than when more su- perficial tissues are being handled. Nitrous oxid-oxygen, or gas-oxygen as it is commonly called, is now being gen- erally used in the larger centers for in- duction in practically all major opera- ^wo questions unanswered through- tions, and as the only anaesthetic for ^^^ ^^^ ^^^^ ^^^^^ ^^ ^^^^ ^^^^ answered minor opertaions m which a general an- ^^ ^^^ satisfaction of at least one man. aesthetic is used. It is replacing ether Heretofore the world has not known in many major operations. Generally ^^^^ .^ speaking, it is safer than chloroform, ^^ „ \ r^ 4.4- tvt j- i -rw 4. ether, ethyl chlorid, somnoform, or any ^I\^^Z\\P''^^-T.' ^^^i'^^\^''^^^}'''' other mixture of anaesthetics. «/ ^he State Hospital at Trenton, New Jersey, tells us what insanity is and he tells us also how he cures it. He de- fines insanity by denying its existence. It is not. But it is caused by infection. ^ Mind is a manifestation of matter. , ,, , , , , ^ , , Normal mind is a manifestation of cer- In the May "uniber of the Long Island ^^-^ ^^^^^^ functioning in orderly fash- Medical Journal, Rathburn, of Brooklyn, j^^ j^^ abnormal mind, or insanity, is discusses urological diagnosis. He very ^^^ ^.^^^It ^f abnormal functioning of properly states that this branch of ^he brain, the creator of the mind, and diagnosis approaches nearly to an exact ^he brain is put in disorder by infection, science, this having been brought ^his disordered mental activity is not about by the development of direct phy- ^^ gj^^i^v, no more than is the body tem- sical means of investigating the urinary pgrature, but it is only the result of ^^^^^' phvsical activity taking place in the Attention is paid, too, to the burden ^rain. Function implies the existence placed on the patient when he is sent ^f structure; if the functioning be dis- from family physician to laboratory, ordered it is impossible to escape the as- from laboratory to urologist, from uro- gumption that the underlying structure logist to radiologist, and so on. jg likewise disordered. So reasons Cot- In his own service complete diagnosis ton. at one sitting is aimed at. Rooms are He has long been engaged in work arranged and examinations timed so with mental patients, both in this coun- i.u 4. 4.U -11 u 1 1- 4-- 1 try and in Europe. For several years that there will be no duplication, no loss ,^ ,,. . , ^ 1 • ^1 ..• ^ ^. , , . he states that he made his therapeutic of time and no petty annoyances. Inci- approach to mental disorders through dentally expediting the examining pro- psychotheraphy, but he got nowhere cess makes it possible to reduce the cost and he began to look elsewhere for an to the patient when complete and re- understanding and a rectification of the peated examinations are necessary, condition. ^^In almost^ ^1^1011^" In^'an while close contact between the several Xr^'to^imp'^rove'the physica'l'condition examiners facilitates intelligent balanc- ^^ ^lis patients he began to clear up the ing of the cost in money and time of a infection, but he soon discovered that certain examination against the infor- removal of .infection brought removal mation likely to be gained. of insanity, and lo, the patient was as if The reviewer is in hearty agreement ^^e or he had not been insane Infec- .,,,,., , , - , tion was found about the teeth, in the with the ideas expressed, and feels sure ^^^^^.,^^ .^ ^^^ stomach, in the colon, and that every urologist who has based his ^^ ^he genito-urinary apparatus. From practice on such ideas has been gratified these foci of infection springs all insan- at the advantage to patient and doctor, ity. Remove the infection in time, be- 378 SOUTHERN MEDICINE AND SURGERY July, 1922 fore the toxins have destroyed the brain is wholly physical origin, nor does he substance, and the mental disorder know that all the agencies that are cap- clears away as frost disappears before able of disturbing it are embraced in the rising sun. Infected teeth are ex- the material world. But he has zeal, tracted, diseased tonsils are enucleated, apparent sincerity, and he is doing his and if mental recovery do not make its best to throw light on a dark field in appearance shortly, then the colon is medicine, and to make many sick people taken out, and, then, if sanity do not well again. Dr. Adolf Meyer writes a assert itself, the only comforting con- foreword for the book which the book elusion left for the surgeon and the would be just as well off without. psychiartist is that they did not get the The little volume of 201 pages was patient soon enough. The toxins had issued from the Princeton University already done their irreparable damage. Press in 1921 ; it is made up of a series Out of a thousand patients detoxi- of lectures delivered in Princeton Uni- cated (Cotton's own word) by surgical versify last year, and it is entitled: means within the past few years, re- "The Defective, Delinquent, and In- covery from the mental disorder prac- sane." tically always followed. In the book he cites in detail twenty-five of the cases. In this column in the June number of Almost any asylum superintendent, this Journal an article entitled, "Amer- however, could describe with great par- ica and the Opium Trade" was review- ticularity the condition of twenty-five ed. It was written by Ellen N. La- or a hundred or several hundred pa- Motte, and was published in the Atlantic tients that recovered, none of whom Monthly for June. In the same number had received surgical attention, and all of the Atlantic answer is made to Miss of whom were still in possession of their LaMotte by Girga Shankar Bajpai, in an teeth — good and bad — after recovery, as article captioned, "India and the Opium well as in possession of tonsils and an Trade." It is assumed from the author's intact almentary canal. About a third name that he is a native of India, but of all- mental cases recover, regardless he writes English in charming style, and of what may be done to them or for makes vigorous but polite reply to Miss them. That the remaining two-thirds LaMotte's charges against his native of all cases of insanity can be cured by government. surgical procedures will await further The author asserts that of all the proof. Disorder of the physical being great opium-producing countries in the through infection and other wise often world India is the only country in which reflects itself through the mental do- the production, manufacture, and sale main in the form of so-called insanity, of the drug is under government con- Paresis, for instance, is a physical dis- trol. The effort to make this control ease, accompanied by progressive and effective by the Indian Government disabling loss of mind, and the mental makes it necessary for the government disorder associated often with fevers to monopolize the problem. In Turkey and the anaemias and other serious met- and in Persia, where opium is also pro- abolic conditions is only a manifestation duced in considerable quantity, the gov- of an abnormal physical state. Because ernment exercises no control over the the mind is upset not infrequently by drug, and for that reason its use in the action of physical substances on the those countries is greatly abused. For brain does not mean that the mind may several years the Government of India be lacking in susceptibility to influences has exercised the most rigid control which cannot be isolated or detected in over opium — its production, harvest, the laboratory. The emotions, for in- manufacture, distribution, and its use. stance, whatever they may be, enor- As a result of this monopoly, according mously affect the intellect. to the author, the population of India But Cotton does not know that mind uses less opium per capita than does the July. 1922 EDITORIAL 379 population of the United States. This two were in the dorsal region, two in the statement is scarcely useful as a reply dosolumbar region, and seventeen in the to Miss LaMotte, inasmuch as one of her lumbar region. Of the last named, chief contentions is that India makes eleven were in the fifth lumbar vertebra, possible, if she does not encourage, the There was a definite history of severe smuggling of opium into the United traumatism in the cervical case, in the States and into other countries from two dorsal cases, in the two dorso-lum- India. It would seem that it is possible bar cases, and in twelve of the lumbar for a resident of India to purchase and cases. In five of the last, the injury to have in his possession at any time not had occurred in childhood. The symp- in excess of two fifths of an ounce. toms in three cases, except those of India does license the production of short duration occurring immediately the poppy, the manufacture of opium after the injury, did not appear until and its derivatives, and the government adult life when ossification of the ver- licenses also houses and shops to sell the tebrae was complete. In one case there drug. Violation of the law is scarcely was a history of slight injury, and in necessary, if any individual in India's four cases no history of injury. Four population of more than 300,000,000 patients with displacement of the fifth people is permitted to purchase almost lumbar vertebra had imperfect first a half ounce of opium whenever he sacral arches. In each the fusion was wishes to do so. In her dealing with made to include at least one healthy bed the problem one finds it easy to believe for eirht weeks and required to wear a that the British Government may be support for from two to four months actuated not so much by the desire to longer. The support in each instance lessen from year to year the use of was of the Taylor spine brace model, ex- opium in India as to keep filled her cept in the lumbar cases, when it was coffers by the inflow of the tax on opium, shortened above to extend only to the It is indefensible for any government to tip of the scapula, and lengthened below attempt to grow fat on the depravity or to grasp the pelvis. The result in vir- the weaknesses of its subjects— wheth- tually all cases was complete relief from er through an indirect tax on a vicious symptoms with resumption of usual ac- habit — opium using or w^hiskey drink- tivities. ing — or in any other wav. The taxation of a people that they mav be permitted OBSERVATIONS BASED ON A Iv without official molestation to STUDY OF INJURY TO THE Orthopaedics Alonzo Myers, M. D., Dept. Editor gratify a depraved and a destructive ELBOW. craving in a perversion of governmental a careful study of X-ray plates in the function. normal elbow shows that if the joint be flexed to a right angle a lateral view shows the capitellum occupying the sig- moid cavity. In early life there seems to be a wide separation between the ar- '^ ticular surface of the capitellum and the FRACTURE DISLOCATION OF great sigmoid cavity, but with growth SPINE. the capitellum comes to occupy the en- Statistics on fracture dislocation of tire cavity. In cases of injury there is a the spine was started while I was House disturbance of this relationship between Surgeon under Dr. Hibbs in 1916 at the the capitellum and the greater sigmoid New York Orthopaedic Hospital. I con- cavity. sider the following report of his study A plane passed through the middle of instructive and valuable. the long axis of the humerous prior to Of the twenty-two cases of fracture- about the eighth year passed behind the dislocation of the spine reported by posterior border of the capitellum ; after Hibbs one was in the cervical region, this period the plane bisecting the shaft Roentgenology — Robt. H. Lafferty, M. D.. Dcpt Fdi tor it ij 380 SOUTHERN MEDICINE AND SURGERY July, 1022 of the humerus has approximately two- thirds of the lower epiphysis anterior to it. A plane at right angles to the base of the capitellum and bisecting it inter- sects the plane through the middle of ^t the last meeting of the American the long axis of the shaft at an angle of Roentgen Ray Society held in Washing- about 130 degrees. With the forearm ton Dr. Hans Holfelder of the Univer- extended on the arm and supinated, a sity of Frankfort read a splendid paper , ^, 1 -1 , . ^ on The Underlymg Prmciples of the plane passed through the long axis of Radiotherapy of Malignant Tumors at the humerus is intersected by a plane the Surgical Clinic of Professor Schmie- through the middle of the axis of the den of the University of Frankfort." ulna at an angle of approximately 170 This paper is published in full in the degrees. A careful history and thor- June issue of the American Journal of ^ . ^ Roentgenology. This article closes as ough clinical examination plus the use foUo^s: "In a few closing sentences I of these planes in the study of the desire to set forth the present status of X-rays will aid greatly in establishing our clinical experience and the indica- the diagnosis in cases of supracondylar tions which determine our handling of , ,. f -u 1 cases at the Surgical Clmic m Frank- fractures and separation of the lower ^ , humeral epiphysis. They are also of «i Every operable cancer, with few great value in determining if accurate exceptions, is operated and in addition reduction has been obtained. receives prophylactic radiation after- T , , . f ■ •,_• „ i.^ 4.u^ ^^v,^,ri.^ wards. The radiation is carried out ex- In treatment of injuries to the condyle ,, . . ,, ,, ,.,, , . , actlv as if the growth were still present, and separation of the epiphysis, the ..g. Beside prophylactic after-radia- acutely flexed position is used whenever tion, radiation before operation is gen- it is possible. Emphasis is placed on erally practiced and is considered of position of the forearm with reference great importance. , ,, T i? i- ^ 4.V • 4- ^„i "3. All inoperable cancers and all re- to the arm. In fractures of the internal a- ^ a i + -p a currences are radiated unless too far ad- condyle the forearm should be placed in vanced. In a certain proportion of cases pronation because contraction of the clinical healing will result in a further pronator teres tends to pronate the arm improvement sufficient to permit opera- and to pull the bony fragment away tion to follow the treatment, and in many , , ^ ,, , T „ cases the danger of bleeding, ichor, and from the shaft of the humerus. In frac- p^j^^ ^^,jjj ^^ diminished or disappear tures of the external condyle, the posi- and the chance of metastasis be dimin- tion of greatest stability is hyperflexion ished. and supination. "4- Where the primary growth is op- erable but there are remote metastases The after-treatment is important, and jn other organs, as, for instance, a pri- as hyperflexion results in contracture of mary cancer of the rectum with metas- the flexor group of muscles, it is essen- tases in the liver, the primary growth ,. , ^ ,. . . , ^ . , -4. :„ is removed by operation and the metas- tial to dimmish flexion as early as it is ^^^^^ .^ ^^^ [.^^^ ^^^ ^^^^^^^ ^^ ^_^^^ safe. Usually extension is begun on the ^lone. tenth day but should be limited by pain. '-5 Epitheliomata of the skin are ex- The position of flexion with the arm clusively dealt with by X-ray treatment, across the chest leads to weakness of "6. The great majority of sarcomata the external rotators of the arm, and jre treated by radiation alone. The time has passed when amputations for sar- therefore exercise of these muscles ^oma are made any longer in the Frank- should begin early. fort Clinic. Apparent increase in size July, 19' EDITORIAL 381 of growi;h following radiation should It is impossible to train a bird dog by not lead to discontinuance of treatment simply letting him bore in the field with or to amputation. other dogs and giving him food and "7 Our method has been mainly shelter. He must have personal atten- based on the technique of Settz and tion, be properly directed and his weak Wintz. We have attempted to adapt points be overcome by the constant at- their methad, by means of the field tention and thought of the trainer, selector and topographical sections of The doctor should not criticise the the body, to the field of surgery. nurse for not seeing and thinking as he "8. Improvement in the technique or does if he has not used his best thought X-ray treatments must be based upon and time to train her to see and think careful and accurate observations and as he does. The hospital staffs in North practical experience carried over a long Carolina so far as I have been able to period of time, involving careful studies find out have not devoted a single hour and adequate records. or set aside a single meeting for the pur- "9. The aim is to secure a home- pose of getting together on the problems geneous radiation of the whole seat of of how to train the nurse; one of the the disease, the dose to be determined by most important factors in operating a the biological qualities of the case. hospital and caring for the sick. "10. Unscientific and improper radia- tion will gravely complicate any case and make ineffective suitable procedure applied afterward. The prognosis of improperly radiated cases is bad News Items '11. Once a case has been radiated in yhirtv-Seven Doctors Licensed to a given institute it should pursue the ,,^^^,j^^ Medicine in North Carolina.— treatment only at this institution and ^^^^^^^ ^^ ^^^ examinations held in Ra- under the same responsibility. Surgical . 26-30 for medical students co-operation is of greatest importance. ^^^^ ^„,,„„,ed Saturday night, July 8, "12. The frequent changes in tech- ^^jj^^^.j^g ^ meeting in Raleigh of the nique and continual advances in the field ^^^^^ ^^gdical examinating board. Forty- of radiotherapy make it impossible to ^ presented themselves for the distinguish statistically between the ^;^ J^^^j^^^ twirty-seven of whom value of operative and radiative treat- examin- \. a o ^ Orange County Medical Society. Richmond, Secretary. The membership of the Sixth District Medical Society includes all members in ^r. Finley Gayle and Dr. J. H. Roy- good standing of the following county ster, of Richmond, recently enjoyed a societies : Alamance, Caswell, Durham- motor tour through the Valley of Vir- Orange, Franklin, Granville, Person, ginia. Vance, Wake and Warren. Dr. Foy Roberson Durham, is presi- d^. q. B. Darden, of Richmond, re- !!H^ ;3^;xF-/'"''^J'J''f''''"^''^^"^' cently spent a few days in Western and Dr. B. W. Fassett, Durham, secre- ^orth Carolina, tary. Dr. W. L. Moss, a native of Athens, ^r. H. D. Masters, of Richmond, has Georgia, a graduate in letters from the spent a brief vacation at his former University of that State, and a graduate home in Fredericksburg. in medicine from Johns Hopkins Uni- versify in the class of 1905, comes to Dr. Thos. A. Matthews, Castalia, N. the Medical College of Virginia in Rich- C. ; University of Maryland School of mond at the opening of the Fall session Medicine, Baltimore, 1890 ; member of to become all-time Professor of Medi- the Medical society of the State of July, 1922 EDITORIAL 385 North Carolina ; died, April 29, aged 54, unit of the Huntington State Hospital, following a long illness. of which Dr. Lewis V. Guthrie is super- intendent, and was erected at a cost of Endowment for Medical School. — It is $80,000. The building will accommo- reported that Wake Forest College date fifty patients. A new bakery has School of Medicine, Wake Forest, is en- also been added to the hospital, with a titled to receive the principal of a trust capacity of 2,000 loaves daily. fund, amounting to $1,375,000, which was created in 1892 by Jabez A. Bost- Dr. Theron Earl Roe, Tigerville, S. C. ; wick, a director of the Standard Oil College of Physicians and Surgeons, Company. Baltimore, 1910; died suddenly. May 11, aged 34, from cerebral hemorrhage. Physician Decorated by France. — Dr. Alonzo Myers, Charlotte, was decorated Dr. Willard Strickland, Wendell, N. C, with the Medaille d'Honneur des Epi- and Miss Cleo Mariner of Pocomoke, demies at Camp Bragg, Fayetteville, Md., were married at Richmond, Va., May 20, by General Pershing. This is May 10th. the second medal Major Myers has re- ceived from the French government for Dr. Walter C. Hemingway, Hem- his services during the World War. mingway, S. C. ; Medical College of the State of South Carolina, Charleston, Medical Meeting.— The first annual 1900 ; died, June 3, aged 45, from burns meeting of the Caldwell-Catawba-Lin- received in the explosion of a gasohne coin County Medical Society was held tank when he was sterilizing some in- at Lincolnton, May 9, under the presi- struments. dency of Dr. L. A. Crowell. The fol- lowing officers were elected for the en- Dr. Franklin P. Gates, Manteo, N. C, suing year: President, Dr. Jacob H. Bellevue Hospital Medical College, New Shuford, Hickory ; vice president. Dr. M. York, 1886 ; member of the Medical So- Caroline McNairy, Lenoir, and secre- ciety of North Carolina; died. May 20, tary-treasurer. Dr. William P. Speas, at Norfolk, Va., aged 62 from valvular Hickory. heart disease. Publications Received College Dean Honored. — The degree of doctor of laws has been conferred on Dr. Robert Wilson, Jr., dean of the Medical College of the State of South Carolina, Charleston, by the regents of j^^^ Thyroid Giand-ciinics of George w. Criie, the college. M.D., and Associates, at the Cleveland Clinic, Ohio. The Thyroid Gland. Octavo of 228 pp., Society Reoiganized.-The Marion ^'^^ i06 illustrations. P^i;^^^«^P^;j,_^^^^.^^^^^^^ ^ , 1,^ T , r-, • i don: W. B. Saunders Company, 1922. Cloth. County Medical Society was re-organ- ^^ qq ^^^ ized April 11, with the following offi- ^his volume is the first of a proposed series cers: President, Dr. Enoch M, Dibble, of clinical volumes, the purpose of which is to Marion; vice president. Dr. Claudius F. present the present theoretic and practical Rullnrk Nirhnls and sprrptarv Dr viewpoints of the author and his associates. ^uuock, mcnols, and secretary, Ur. ^^ .^ ^^^ ^^^.^^^ ^^ ^ ^^^^ ^^^^^ ^^^ i^ o^^iy Frank L. Martin, MuUins. The meeting ^s a publication representing the present ideas was held at Mullins, S. C. and practices in connection with thyroid dys- function and pathology. The author advocates the proper administra- Federal Mental Clinic. — A new fed- tion of lodin to the pregnant mother and the eral clinic for the diagnosis and treat- child up to and through the period of adoies- , J. J ,1 1 i^ • j^ • i-pnc9 which procedure he believes will make ment of mentally deficient ex-service ^^^'/..rof goitrous regions as goiter free as men has recently been completed at ^,.q ^j^g children of the seashore. Huntington, Va. This institution is a After the 25th year, iodin exerts little or no 386 SOUTHERN MEDICINE AND SURGERY July, 1922 beneficial effect on goiters. The improper use of iodin or thyroid pro- ducts is responsible for the conversion of many cases of quiescent goiter into exophthalmic goiter or iiyperinyroidism. Basal metabolism estimation provides a val- uable, but not a specific test for the presence of hyperthyroidism and are of little value in the determination of the operabiliiy or prog- nosis of cases of hyperthyrodism. "We no longer use liot water injections, qui- nin and urea injections, ex-ray or radium; but we add to surgical treatment a planned regimen of rest and diet just as if no operation had been performed." "In view of the surgical results we advise sur- gical treatment for all cases without regard to the degree of hyperthyroidism." Practical Therapeutics — By Hobart Amory Hare, M.D., LL.D.. B.Sc, Professor of Thera- peutics, Materia Medica, and Diagnosis, Jef- ferson Medical College, Eighteenth Edition, enlarged, thoroughly revised and largely re- written; 1038 pages, 144 engravings and six plates. Price, $6.50. Lea & Febiger, Phila- delphia and New York. This eighteenth edition follows the same practical arrangement as do the preceding edi- tions, and has been revised so as to include the most recent developments in the field of therapeutics. Dr. Hare himself says. "The author must hold fast to that which is good and cast aside that which has become obsolete, but in doing this he must not permit his desire to accept the new to overcome respect for the old, if the old has the endorsement of long experience on the part of his fellows and himself.'' 1921 Collected Papers of the Mayo Clinic, Ro- chester, Minn.— Octavo of 1318 pages, 392 illustr;ations. Philadelphia and London. W. B.' Saunders Company, 1922. Cloth, $12 net. Possibly no publication is more cosmopoli- tan in the medical field than is this compila- tion of original papers, and none portrays more dependably the present day knowledge of the science of medicine. In this book there are the contributions of more than 80 individuals and about 20 com- binations of authors. Then, remembering the extreme care with which the findings and observations of these hundred best students has been edited, we can e assured of accuracy and reliable in- formation along almost any line of scientific madical investigation. Clinical Laboratory Methods — By Clyde L. Crammer, Ph.B., M.D., Associate Professor of Clinical Pathology, School of Medicine. Western Reserve Univerfeity, Cleveland. 484 pages with 136 engravings and eieht plates. Price $5.50. Lea & Febiger, Phila- delphia and New York. This manual Is devoted largely to a descrip- tion of laboratory methods and technic, but also very lucidly outlines the underlying prin- ciples, the indications for performing tests and the significance of results. The plan adopted in most chapters is about as follows: (1) Outline of routine examinations; ^2) description of the simpler qualitative methods which are frequently employed; (3) descrip- tion of quantitative methods or those intricate technic; (4- discussion of findings in various moibid conditions. When several methods are given, the author indicates his preference. The Eighteenth Amendment and the Part Played by Organized Medicine.. By Charles Taher Stout. Publisher, Mitchell Kennerly, New York. The preface begins thus: "The first pages of this book were included in a paper written as a protest against the candidacy of a regular army officer who was seeking the nomination of one of the great parties for the office of President of the United States. This general officer had entered the army through the medical branch of the service and still main- tains his membership in the medical organiza- tion, which expected to avail itself of his ad- ministration (if that ever became a reality) to push its special legislative programme.' Attention need hardly be called to the im- possibility of any one knowing what the med- ical profession expected to do, or td the ridiculous attempt at a slur on General Wood. The stream flows not up from its source. The body of the effusion is made up of mis- statements of facts, empty, rhetorical phrases, inunendoes and downright abuse. Every chapter shows smug assurance of knowledge of pharmacology and physiology beyond that possessed by any man. There is only one man whose knowledge of medicine is incomplete: that is the doctor. Hay Fever and Asthma. By Wm. Scheppe- grell, A. M., M. D., President American Hay Fever Association. Lea and Fibriger. This is probably the most comprehensive work on the subject of hay fever. The au- thor's extensive research over many years qualify him to speak authoratitively; yet it is far from being dogmatic. It is simple and attractively written and would be entirely understandable to the in- telligent layman. The Practice of Medicine. By H. H. Stephens, A.M., M.D., Prof, of Applied Therapeutics in the University of Pennsylvania. This is one of the best of the single volume works on practice. The classification according to etiology so far as known and including a group of "doubtful etiology," is excellent. Modern methods of diagnosis and treat- ment are included in so far as they have July. 1922 BOOK NOTICES 387 been sufficiently tried out. ters have been added. One of these, on An especially gratifying incident is that Paraphrenia, deals with a class of rath- fixation of sp. gr. is given as a more valuable ^^ ^^^^ psychoses, which the average differential diagnostic sign than albumen or , . . , . , , casts in the urine. physician rarely recognizes, but upon The whole.some skepticism, as to the general ^^^i^h, the author claims, considerable value of organotherapy recommends the work light may be thrown by psychoanalysis, as that of a reasoner rather than a visionary. rru„ i au i. j. i xi . • The work throughout reproduces the Symptoms of Visceral Disease.. By Francis ideas and teaching of Dr. Sigmund Marion Pattenger. C. V. Mosby Company, Freud. St. Louis. The introductory deplores the tendency to i? 4u on neglect bedside for laboratory methods. This Erythema Bullosum. can not be too often mentioned. Emphasis is T7'„,,i.-u^^^^ u,,n^„ ■„ „ *. ^ ^-e , 1 , ,, ,. 1 r iu li,rvtnema bullosum is a rare type oi also placed on the very great value of theor- - , . , izing. In a practical age we are likely to erythema multiforme m which the ex- despise theory. udation is so rapid and extreme as to The postulate is laid down, "The vegetative cause bullae in addition to the edema system, when its normal action is disturbed, which occurs in some of the more com- is the chief cause of the symptoms of visceral ,^ ^ ^„ t o it; ^4-„„j^ /~>u,-„.,™^ ,. n,, r\ X. -i-i J J. i. mon lorms. J. S. bisenstaedt, Chicago disease?" One may be permitted to suggest ^^ , . t, . ,, ^ .^^^x , that the cause of visceral disease is also the (Journal A. M. A., May 6, 1922), has cause of the disturbance of the normal action studied five patients suffering from a of the vegetative system. severe form of erythema bullosum. Due attention is paid to the changes brought -i /? i j i. i -n about by abnormalities of the psyche. ^hree of whom were desperately ill. The inter-dependcnce of organs is dwelt These cases seem to indicate that ery- upon and attributed to reflex action, with the thema bullosum is a disease due to toxic more or less new qualifying word "viscerogen- substances. The toxic substances may ice" prefixed. "Reflex action" satisfies the , j. -j i -i-rr . t • earnest doctor far less than the patient. be from Widely different sources. In at- Referred pain, a term used by the author tempting to find an etiologic factor in interchangeably with reflex, is more satisfac- different cases, it is well to rule out fo- tory. It explains nothing; it professes noth- ^.^j infections from the teeth, tonsils, ^,, ,, , J .,, ,, etc. Any focal infection present should Whether or not a reader agree with the . ' i^ .. .• /•- j.i i more e..treme features of the work, he will receive expert attention after the sub- find much to instruct and entertain him and to sidence of the attack. Treatment di- influcnce him to e.xamine and ponder. rected to alkalizing the patient to the .Applied Chemistry. By Fredus N. Peters. "^"^0^^ and giving large doses of salicy- Ph., D. C. V. Mosby Co., St. Louis. lates is of great value. Protoclysis for This is an entertainingly written book on the exhibition of alkali salts and salicy- what is usually said to be a dry subject. It is lates is indicated when the patient can- gratifying alike to the speculative philosopher j^^^ ^^j^g fluj^jg ^y rtiouth. Regardless and to the severe practicalist. It impresses „ , , ^ -i j-i- on the reader the debt humanity owes to the of how desperate the condition may ap- chemist through all the ages emphasizing the pear, recovery usually takes place un- valuo of knowing things for the sake of ^qy appropriate treatment, knowledge without neglecting to cite innum- erable instances of the application to our ' daily needs. ^ "Diabetic Ulcers." Psychoanalysis, It's Thoeries and John Hudson Storer, M.D., of the Practical Application, by A. A. Brill, Community Hospital, New York City, Ph. B., M. D., Third Edition, 468 pages, in an article on Diabetic Ulceration, W. B. Saunders Company, Philadelphia which condition he characterizes as one and London. of the most difficult problems the doc- This, the third edition of this work tor has to deal with, said: "Ulcers oc- contains the same teachings we have curring in the latter stages of Diabetes become familiar with in the former edi- Mellitus, are impossible of cure, but the tions but much new material has been patient should have relief from the in- added in the revision and two new chap- tense agony, and naturally calls upon SOUTHERN MEDICINE AND SURGERY July, 1922 Table of Contents for July, 1922 Original Communications. The Significance of Nasal Polys, by H. C. Shirley, M. D 369 Diagnosis in Non-Valvular Cardiac Disor- ders, by R. F. Leinbach, M.D., and Wm. Editorials. Allan, M.D. 333 Disorders of the Heart Mechanism, by J. On Locating the Medical School of the Uni- P. Munroe, M.D. 338 versify 372 Illustrations of Differential Diagnosis of Will a Physician be Compelled by Law to Some Torpid States with Case Presenta- Treat All Persons Requesting It? 374 tions, by Tom A. Williams, M.D 344 Begin New Work at Rex Hospital 375 Surgical Significance of Pain in the Left Side of Abdomen, by R. L. Pittman, M.D. 348 Department Editors. Radium Therapy in Certain Benign and Ma- . ^, .,, , ,^ t^ or,r- lignant Conditions, by Wm. D. James, Surgery, A. L. Baker, M.D 37d M.D., and A. W. James, M.D 351 Urology, A. J. Crowell, M.D 377 Acute Parenchymatous Glossitis, with Re- Mental and Nervous, Jas. K. Hall, M.D 377 port of Three Cases From the Episcopal Orthopaedics, Alonzo Myers, M.D. 379 K ^HoHowa''* Philadelphia, by Jackson ^^^ Roentgenology, Robt. H. Lafferty, M.D._.._ 380 „. ■, , , ' ,' . C"~T "tt ^ "T Hospital and Sanatorium, John Q. Myers, Disclosed by the Urine, by J. Henry Dowd, ^ oot M.D. 362 MD. 381 The Legal Phase of the Problem of Feeble- News Items 381 Mindedness, by J. C. Lanier, Attorney 365 Publications Received 385 the doctor to do that which he himself much relief and comfort to the long- knows to be next to impossible. suffering patient. These ulcerations usually occur on if the ulcer is not inflamed, cauter- the lower extremities, more often on the ize or remove with a sharp spoon all feet as a result of the breaking down foul granulations or debris. Dress with of the gangrenous tissue; and even adhesive zinc plaster, or zinc and though this condition occurs late in the icthyol ointment, or with plain mutton disease, every effort should be made to ^^^^ j ^jg^ strongly recommend the relieve the suffering caused thereby, ^ j.- t.i • 4.- ,-^- v,^i,-«,raa , , . . ,. ^, , , ,, , ."^ use of antiphlogistme, as it reheves delaying for a time at least the admin- ^ . , x- j istering of the inevitable narcotic, first P^i", increases circulation, and pro- by mouth, then as the disease pro- motes granulation. In some cases re- gresses the dreaded hypodermic, end- lief is had by using hot compresses of ing finally in the first amputation. witch hazel or boric acid solution." In our limited armamentarium we ^ have little to make this picture any the FOR SALE less harrowing. Not going into the internal treat- One Horley M. Jones basal metabol- ment of this disease, I will confine my ism apparatus in perfect condition; also remarks to the external or palliative f"" oxygen tanks, charcoal, and sodium asr)P.t of the condition. hydrate for use with same Reason Onv f^eld is very limited, but there ^^^ sellmg: installing Tossat type of are a few suggestions that I have found apparatus. SUPERINTENDENT, to be of considerable benefit and afford Sanatorium, N. C. Southern Medicine and Surgery Vol. LXXXIV CHARLOTTE, N. C, AUGUST, 1922 No. 8 was "insanity in the family" the patient was considered as suffering from here- FOCAL INFECTION THE CAUSE OF ditary taint. This phenomenon occurred MUCH MENTAL DISTURBANCE.* ^" a sufficient number of cases to sub- stantiate the idea that heredity taint By Henry A. Cotton, M.D.. Trenton. N. J. '"'^^ ^^e principal factor. . , We do not want to be misunderstood Suporintendont New Jersey State Hospital. , ,. i i , i ■,-. ^ ■, ^ •!_ ' •^ ' as we believe that heredity has a definite role in the psychoses, but we feel that For many years those interested in too much importance of heredity is ex- the general problem of the insane and tremely fatalistic for if a patient is born feeble-minded were inclined to adopt a ^ith the potential element of mental fatalistic attitude in regard to the treat- disorder then there is little use of trying ment of these conditions. Consequently, to prevent a psychosis or to successfully custodial care has been the basic prin- arrest it if it does appear. Hence the ciple involved in these matters. If a attitude was adopted that only by meth- patient was insane he was placed in q^s of training, education, and environ- an institution for the protection of oth- mental advantages could these symp- ers as well as himself and if he was toms be forestalled. But, we have ob- feeble-minded the protection of the com- served many cases where the environ- munity was of paramount importance ^ent was extremely favorable, where and the training of the individual sec- education and training were all that ondary. could be desired, and in spite of this a Such a situation arose largely from psychosis developed. our previous lack of knowledge of the p^om a biological standpoint, here- causes of these various mental abnor- (jitv means something very definite and malities and co sequen .y there was no one has only to read Conklin's book, adequate treatment which could be sue- "Heredity and Environment," to get the cessfully instituted to restore these peo- correct idea. It is a well established fact pie to normal activity. Our fundamen- that the mental activities which we tal knowledge of these conditions was designate the mind cannot be considered based largely on speculation and coin- apart from the brain. In other words cidence and the real cause remained a we cannot have function without struc- mystery. One of the fundamental er- ture and this being true there can be rors particularly pertaining to the psy- do abnormal function without a corre- choses has been the role given to here- sponding abnormal structure. dity as a causative factor. So fixed has in general medicine we see more and this become in the minds of the pro- more a tendency to discard "functional" fession, laity and psychiatrists as well disease for the organic type. Hewlett that for years it was considered the has recently stated, "It is true that in principal underlying factor- It was the last analysis all disturbances of largely through the loose way in which function must be capable of explanation statistics regarding heredity were col- j^ terms of physical or chemical changes lected in state hospital records that such [^ the body cells and fluid." This view- an opinion became prevalent. If there point is more readily accepted in dis- ~~'~ , . ,, ,, . , .. . , T. ,- eases concerning the body in general ♦ Read at the Memorial Exercises and Dedica- ,, , i- j j. 4-u„ -^j „„j toin of the Buildings at the Caswell Training than when applied to the mind and School, Kinston, N. c, April 13-14, 1922. brain- Another known scientmc fact 390 SOUTHERN MEDICINE AND SURGERY August, 1922 substantiates the viewpoint that a dis- Our investigations in the last four ordered mind, whether the disorder years have shown conclusively that the could be classed as insanity or defective- psychotic individual harbors multiple ness, must have an anatomical basis, foci of infection which often can be lo- Consequently, in dealing with a mental cated and eliminated only with the disturbance we must first ascertain what greatest difficulty and persistence on the factors are at work which could cause part of the physician. In order to prop- anaton.ical changes in the brain tissue, erly locate and eliminate these multiple This is extremely important if we want foci of infection the psychiatrist has to accomplish anything in the treatment had to call to his assistance the special- of the individual. ist in other branches of medicine. So Infection ^^^^ today a well equipped clinic for nervous and mental disorders is only If then we have destroyed our belief adequate in so far as this principle of in the important role of heredity and group diagnosis is carried out. The psychogeni* factors, what have we to growth of the idea of a diagnostic sur- offer in their place as causative factors, vey of every individual, whether suffer- Formerly the physical condition of the ing from mental disorder or other sys- patient was of minor consideration and temic diseases, has been rapid. One many patients were classed as physically need only to mention the success of the normal, which practice we know now Mayo Clinic and of the work of Lewellys was a serious error. We are indebted Barker, at Johns Hopkins to illustrate to modern medical practice for the the trend of modern medicine. Why methods which permit the finding of then should there be any criticism if the serious physical disease in apparently psychotic individual is given the advan- otherwise healthy individuals. The tage of the application of the principles work of Billings, Hastings, Rosenow, of modern progressive medicine? In Barker and Upson of the medical as view of the successful application of well as Thoma and others of the dental these principles at the State Hospital profession has established, without any at Trenton in the last four years, shall question of doubt, the doctrine of focal we still adhere to the old ideas expressed or massed infections. These infections at the beginning of this paper; or shall were formerly overlooked, not only in we lay pejudice aside, which limited the the psychotic patient but in patients suf- treatment of the psychosis to psych o- fering from various systemic disorders, therapy, or the so-called occupational This doctrine has been the most impor- therapy, and study the individual as a tant contribution of twentieth century whole and endeavor to discover any medicine and the application of the pathological condition which might be methods evolved to determine the pres- present. ence of chronic infection has added an It is only within the writer's short entirely new chapter to the treatment experience of twenty-one years that the and prevention of the psychoses. question of the relation of syphilis to The local foci of infection which paresis was doubted in America. Paresis gives no local symptoms and of which was considered a disease due to over- the patient may be ignorant can cause work, over-mental strain, because it oc- serious systemic diseases, both by rurred in brokers, bankers, actors and spread of the organisms to other parts others who were supposed to be over- of the body and by a dissemination worked. It was considered purely a through the blood streams of the toxic mental disease. First a history of pre- products, the result of such infection, vious syphilis in a large proportion of is still doubted my many, but we feel the cases gave a clue to a better under- l^of fiiTough work has been done to es- standing of the causation. Then the tablish such a doctrine in spite of this studies of the brain cortex of Nissl and skepticism. Alzheimer revealed the fact that very August, 1922 ORIGINAL COMMUNICATIONS 391 serious pathological changes had occur- the result of such infection is properly- red. Finally Moore and Noguchi demon- understood by the profession at large, strated the spirocheta pallida in the It is obvious that when the psychosis brain tissue in cases dying of paresis, can be arrested by eliminating chronic Here we have an example where step by foci of infection then by properly treat- step our ideas regarding the causation ing such patients long before the psy- of paresis underwent a complete revolu- chosis appears the mental disorder can tion and no one would dispute the fact be prevented, today that paresis is an organic, brain ^ ^ » ^ .. disease due to destruction of the brain ^^«"^^^ «^ Infection. tissue by the spirocheta pallida. We have found that the source and The so-called functional psychoses, type of chronic infection in the psycho- we believe today, to be due to a com- tic patient is the same found in many bination of many factors, but the most of the systemic disorders. We may be constant one is the intracerebral, bio- pardoned, perhaps, if we claim that our chemical, cellular disturbance arising vvork in the elimination of focal infection from circulatory toxins originating in has gone further than in most clinics, chronic foci of infections situated any- We have utilized what we consider the where throughout the body and prob- best methods that have been developed, ably secondary disturbance to the en- Some of them, unfortunate, are not in docrin system. The psychosis then in- general use, nevertheless we are of the stead of being considered a disease en- opinion that time will show all the tity should be considered as a symptom methods adopted by us are extremely and often a terminal symptom of a long valuable in ridding the patient of mul- continued masked infection, the toxae- tiple foci of infection, until better mia of which acts directly on the brain- methods are devised. As psychiatrists have for years recog- We have come to regard the infection nized a toxic infectious psychosis, es- of the teeth as the most constant focus pecially in patients who had an obvious found in our patients. Without excep- infection, acute in character and easily tion the functional psychotic patients diagnosed, we have not established a all have infected teeth- Briefly they new principle when we speak of the may be divided into unerupted and im- toxic origin of some psychoses. But we pacted teeth, especially third molars; have extended the diagnosis to include periapical granuloma ; carious teeth with types such as manic depressive insanity, infection ; apparently healthy teeth with dementia praecox, paranoid condition, periodontitis; devitalized teeth with etc., in which the infection is not ap- either Richmond or gold shell crowns; parent or easily found upon casual ex- extensively filled teeth with evidence of amination. But such infection is only infect'ion; and gingival granuloma in found upon utilizing all the methods of apparently vital teeth, modern diagnosis, so it should not be While the progressive men and lead- difficult to adjust our ideas to these ers of the dental profession are awake views. to all the types of infection, unfortu- If the profession at large can accept nately the "rank and file" are not suffi- this viewpoint, which we feel will be ciently acquainted with these many changed from a hopeless, fatalistic one, forms. Consequently, the physician who previously in vogue, to a hopeful one attempts to rid his patient of focal in- wherein they themselves can not only fection must become acquainted with arrest many cases after a psychosis has modern dental pathology. In our young- developed but better still by eliminating er patients, from 16 to 30 years of age, these foci of infection easily prevent the no matter what the psychosis may be occurrence of the psvchosis. There can diagnosed, we find unerupted and im- be no question that many of the psy- pacted third molars in a largf propor- choses can and will be prevented when tion of the cases- And we would un- SOUTHERN MEDICINE AND SURGERY August, 1922 hesitatingly advise, when there are clinical evidences of systemic infection and intoxication present, that these should be removed. We have found that they are always infected and the infec- tion is in some way related to the fact that the tooth is unerupted and im- pacted. All crowns and fixed bridge work have been condemned by the best men in the dental profession and we voice the same opinion. So in order to rid a patient of focal infection a very thor- ough job must be done and no suspi- cious teeth allowed to remain. This does not mean that every patient should have all his or her teeth extracted, in fact in our work at the State Hospital we would not average over five extrac- tions per patient. Time prevents my going into the question of infected teeth more thor- oughly but I would emphasize the fact that a thorough elimination of focal infection can only be obtained by extrac- tion. All other methods have proven worthless and dangerous to the general health of the individual. We would like to call attention to the method of removing the infected teeth. In many cases simple extraction is not sufficient, even when the socket is thor- oughly curretted. When the alveolar process is severely involved, the Novis- ky method of surgical removal is abso- lutely necessary. Failures to get results from removing infected teeth are fre- quently due to the fact that diseased, infected, necrotic bone is left and ab- sorption continues even after the teeth are extracted. Chronic infection of the tonsils is equally important as infected teeth and the mouth cannot be considered free from infection when infected tonsils are not removed. It is a striking fact that very rarely is a patient admitted to the State Hospital at Trenton whose ton- sils have been previously removed, so that over 90 per cent of the patients have to have their tonsils enucleated after admission That the children of th^ nrcsent generation are having their infected tonsils enucleated, will, we be- lieve, have a definite influence on the elimination of systemic and mental dis- orders later in life. Whatever may be the result of treating infected tonsils with the X-ray or local therapy, we feel that today enucleation is the only meth- od permissible- Types of Bacteria Concerned in Chronic Infection. Briefly stated, we have found the va- rious types of streptococci and colon bacilli responsible for chronic infection in our psychotic patients. The strep- tococcus group composes many strains, as cited below. The colon bacillus group is also made of various strains, differ- entiated by their cultural reactions in carbohydrate media. Below is given a table showing the strains of streptococci classified accord- ing to Holman. These sixteen types represent the grouping of 1,122 strains of Holman and taken with strains from the literature the total number is 2,463, a sufficient number to come to some conclusion as to their biological types. While some types can be identified un- der the microscope, only by their cul- tural reactions can they be accurately differentiated. Hemolytic Streptococci. Type Mannite Lactose Salicin Infreq. Plus Plus Plus Hemolyt. i Plus Plus Minus Pyogenes Minus Plus Plus Anginosus Minus Plus Plus Hemolyt. ii Plus Minus Plus Hemolyt. iii Plus Minus Minus Equi Minus Minus Plus Subacidus. Minus Minus Minus Non-Hemolytic Streptococci. Fecalis Plus Plus Plus Hemolyt. i. Plus Plus Minus Mitis Minus Plus Plus Salivarus Minus Plus Minus Non-hemolyt. ii Plus Minus Plus Non-hemolyt. iii Plus Minus Minus Equinus Minus Minus Plus Ignavus Minus Minus Minus We have so far been able to isolate six strains of the hemolytic group, i .e., the infrequenz, pyogenes, anginosis, equi, and subacidus, and five strains August, 1922 SOUTHERN MEDICINE AND SURGERY 393 from the non-hemolytic group, i. e., fe- lowing the bacteria, originating in the calis, mitis, salivarus, equinus and ig- mouth, so that we find secondary foci navus. We have found representatives of infection of the stomach, duodenum, of both these groups in various sources small intestine, gall bladder, appendix o fculture. Occasionally the hemolytic and colon. The genito urinary tract is strains are found in the teeth, but more frequently infected, not only by the or- frequently this type is found in the ton- ganism of the streptococci group but sils and gastro-intestinal tract. Nine- colon bacillus group as well. The source tenths of the tonsils harbor the hemo- of this infection of the genito-urinary lytic strains and also the non-hemo- tract is not altogether known, lytic strains as well, and it is not un- In the females we find at least 80 usual to find two or three strains in the per cent of the cases have a chronic in- culture from the stomach and duode- fection of the cervix-uteri, and while num, both hemolytic and non-hemolytic the body of the uterus is rarely involved types. we more frequently find infection in Later investigations have shown the the adnexia. In the males a certain per- "viridans" is a form of the non-hemo- centage of the acute psychoses have in- lytic streptococcus, but not all of the lat- fection of the seminal vesicles. The ter can be classed as "viridans." So it prostate and bladder, as a rule, are not is bett'T to substitute the exact type for involved, this term Treatment by Detoxication. It is useless to argue which types ^^ , , , , ■ , , j. -, . ■, may or may not be pathogenic, or which ^ ^^ '^"".f^^l "^^,^'"* ^"^ ^^^* ^^' types may be more virulent than oth- been said that all surgical measures ers. We have not found that the hemo- "^^1^^^^ are primarily for the elimma- lytic types were more viulent than the V.^" ^^ ^^e chronically infected tissue other group or that they produced more It has no relation to the surgery prac- marked symptoms. In fact, any of these ^^^^ '^?"^^ y^^\'. ^^^ which was directed organisms may become so virulent at ^^''^'^\ correcting malpositions and the any time that they cause the death of ^'^"^^^^f.^ «^ ovaries and other organs ir- the patient, although for a long time '^':^t''}Zl ' '"^''^^°"- they may be latent and no marked evi- The removal of all infected teeth and , / , 1 . , , , infected tonsils is imperative. Surgical dence of their presence shown other , , .•,• i j? ,, r j.i_ ^ ;• i 4- \\T i-ii measures have been utilized tor remov- than by the fixation tests We are still . , . n ^ ^.v, • -p + j i „ ,, . . 4.U 4. ^v, ^■^ *. c ing portions or all of the infected colon, of the opinion that the compliment fixa- ^^ ^„^ , ^ ^u j ^ i 4.- , . , f +. .1 1 1 J 4^ ] 4- • • The Sturmdorff method of enucleating tion tests ot the blood for determining . j , , • , . the presence of chronic infections are ^" ^" f^ \„^ , , , j J . , 1 i-u 14-- 4.- cessful. When the uterus and adnexia ot value as are also the agglutination • , i i 4. i, 4. 4. ,,,.,, -r. 4.1, are involved a complete hysterectomy is tests lor the same purpose. Further „_„„_„,. _ , -.^Zu.^^l^ ^, ,x.^ ' necessary, and involvement of the sem- inal vesicles necessitates excision and standardization is necessary, however, before they can be used as a routine , . laboratory test. drainage. ^ . . . ,. , . „ Chronic gastric infection and mfec- Dissemination of Infection. tion of the small intestinal tract can From the fact that the elimination of only be treated by autogenous vaccines infected teeth and tonsils produced mar- or specific serum. Autogenous vaccines velous results in some cases and in oth- are made in our laboratory from the ers no results whatever, it was logical bacteria isolated from the stomach by to conclude that the infection had the Rehfus method. We have also de- spread to other parts of the body, veloped a specific anti-streptococcic and through either the lymphatic circula- anti-colon bacilli serum made from the tion or the blood stream, and preferably organisms isolated in our laboratory, by the former. Secondary infection of Every patient receives as routine treat- the stomach and lower intestinal tract ment, first the autogenous vaccine and could also come from constantly swal- later the specific serum. But always 894 SOUTHERN MEDICINE AND SURGERY August, 1922 after infected teeth and tonsils have tremely important and when this fact been removed. The serum has proved is generally understood by the laity and especially valuable in the operative profession it will be the means of sav- cases. Its administration before oper- ing millions of dollars to the states, ation upon the colon has reduced the now paid in maintenance for these mortality from thirty to twelve per chronic patients. Over one-half of the cent. Therefore, if for no other reason, permanent population of state hospitals its use is justified. can be classed as dementia praecox or In our work in the last four years chronic deteriorating types with an at Trenton we have shown definitely average life of fifteen years, that while heredity, environmental con- Feeble-Minded Group. ditions and mental factors play an im- j^^ considering the defective types, the portant role m the causes of mental dis- mentally retarded and feeble-minded, orders, they may be absent and yet a ^^ ^ave found in the past the same psychosis will develop. As early as 1906 situation as we have found in the psy- the writer was convinced from his work ^^oses. Heredity was considered the with Alzheimer m Munich, that there principal factor and in a great many were definite cell changes in the psycho- ^^^^8 this is undoubtedly true. Recent SIS known as dementia praecox. With investigations have shown that the fee- these facts as a basis the problem in the ble-minded type is not a unit, but is last fifteen years has been to find the composed of many classes, and while cause for the anatomical changes in the ^^^^ ^^^^ the influence of hereditary "^^^^' taint in other conditions it is evidently The glands of internal secretions were acquired. For convenience, the feeble- intensely studied for over five years and minded may be divided into two large every known method of glandular ther- groups ; the intellectually defective and apy resorted to, but without benefit to the emotionally defective. Schlapp and the patients. Finally the problem of in- others divide these classes according to fection was taken up following the work the pathological conditions found. First, of such men as Hastings, Billings, Rose- a formative class ; second, a functional now and others, and in the last four class; third, a traumatic class, years, as stated before, we have proved in the formative types the brain is conclusively that the psychosis is due not normally developed, possibly be- to a combination of factors, the most cause of prenatal arrest and the mental important of which is intra-cerebral tox- defect can be ascribed to developmen- emia resulting from chronic infections tal abnormalities- In the functional located in the teeth, tonsils, gastro-in- type there is apparently a normally de- testinal and genito-urinary tracts, and veloped brain, but for some reason it probably other sources which have not does not respond in a normal manner to yet been brought to light. stimulation. This class is the one that As a result of this work we have we ascribe as perhaps the pseudo-feeble- been able to increase our discharges in minded type and the one which offers the so-call«'d functional group from an the best field for treatment. The trau- average of 37 per cent for ten years, matic class comprises the types in which to between 80 and 90 per cent in the the brain has been injured in childhood, last four years This means that for- or at birth, by such disease as menin- merly a little over one-third of these gitis, hemorrhage, or any trauma that cases ever left the hospital, two-thirds has destroyed enough tissue to cause a remaining as chronic patients. Today disturbance. more than two-thirds of this group re- The acquired types which would come cover and are returned to useful occu- in the functional group often exhibit pations in their environment. Aside phenomena of normal mentality up to from the humanitarian aspect of this a certain age. They learn to walk and question the economic one is also ex- talk at the usual age and at first are August, 1922 ORIGINAL COMMUNICATIONS 395 able to learn the elementary subjects, ods of glandular therapy which will be Gradually they become dull, more or of immense assistance in treating such less stupid, show inability to concen- cases. trate or study, fall behind in the grades The following case is reported and have to be placed in special classes through the courtesy of Dr. Max for training adapted to their mental Schlapp. The history of this case shows capacity. that the patient was perfectly well un- In a great many cases which have til his eleventh year. He had made nor- come under our observation, a thorough mal progress in school, in a regular examination has revealed the presence class, but from this time on began to of multiple foci of infection. It is sur- have headaches. He became deficient prising to find that many of these un- in his school work so that he was held fortunates have badly infected teeth, back- Finally, he was examined, de- even at an early age. Malformations clared feeble-minded, and sent to the and maloclusions of the teeth are fre- ungraded class. Here he behaved just quently found and often the extraction as badly. He threw things at the o fthe first teeth, as outlined before, teacher and the pupils. At home he should be insisted upon in these pa- was irritable, cross, and threw a butcher tients. The tonsils should also be knife at his father and stove-lid at examined and removed if infected his mother. Continually shouted, "I and the gastro-intestinal tract inveeti- will kill someone." He rolled his head gated and infected conditions eliminat- in his hands, repeated over and over, ed. We have been impressed with the "Oh! my head." He threw his sister toxic factors found in these cases and against the wall. At times he was very the marked improvement which occurs restless, at others would sit all after- when such factors are removed. noon and refuse to move. He changed Coupled with the toxemia and chronic from an energetic worker to a boy who infections there is frequently disturb- would neither work nor play. A thor- ance of the glands of internal secre- ough examination and X-ray of his head tion. A considerabl-^ amount of inves- revealed an abscess of the frontal smus. tigation has been done to determine the He was operated upon, pus removed effect of disturbed secretions of the from the smus, and he seemed better ductless glands in these cases Disturb- immediately. A report from the teach- ances are especially evident in the cases er a year and a half later showed that exhibiting sexual irregularities. The he was doing normal grade work and interstitial sex cells show a hyperactiv- that all his former peculiarities had dis- itv and aside from causing an excessive appeared and at home his mother re- normal activitv in the sexual life of the Ported that there had been a marked individual the yfrequently cause abnor- improvement in his conduct. Five years mal sexual activity. These sexual irreg- later Dr. Schlapp received a report stat- ularities cannot be controlled by the in- i"g that the boy had been constantly at dividual so long as the irritating and work since leaving school earning $30 stimulating agents are present in the a week- body. It has been a mistake' to try to Dr. Schlapp's comment on this case correct these evils by punishing the is as follows: "I do not believe that c>iild. Instead of this we should at- the direct irritative effect of the abscess tempt to find the factor which is caus- on the central nervous system accounted ing this abnormal sexual activity. In entirely for his inability to adjust him- cases where it is due to toxemia the re- self, but that in this case the adrenal moval of toxic factors will correct the gj^^^j ^as over-stimulated by the toxic abnormalities. It is more difficult to ^. ^^ ^ ,i , u • i, +1. ^ , , ,.,. 1, 4.1, • . effect of the abscess which was the correct such conditions when the inter- , i i tt nal secretions have become extensively cause of the emotional shocks. He was involved, but further investigations in not intellectually feeble-minded, but was this field will no doubt produce meth- so emotionally unstable that he could 396 SOUTHERN MEDICINB AND SURGERT August, 1922 not concentrate and was declared by a very serious intestinal condition. His psychologist to be feeble-minded." tonsils had been removed previously and Dr. Schlapp emphasizes the fact that the teeth showed nothing in particular, all such cases should be treated early Examination of the stomach showed a if good results are to be obtained. Many very low hydrochloric acid content and cases should be treated long before they the presence of streptococci and colon reach the public schools. The process bacilli in the stomach. X-ray studies may be so severe that if continued for of the intestinal tract revealed abnor- a long period it will interfere with the malities of the colon and a very marked normal development of the brain. This delay of the barium meal. There was is especially true of the class known as also a history of severe constipation for cretins where the mental defect is due years. to lack of proper thyroid gland activity. Exploratory abdominal operation was This deficiency of the thyroid gland can performed November 6, 1918, and be treated by thyroid extract, but it marked involvement of the ascending must be instituted early in the child's colon and caecum was found. The me- life. If allowed to go untreated the dis- senteric glands were much enlarged in ease reaches the point in five or six the ileocaecal region, but the lesion years where thyroid extract has no ef- seemed to be limited to this area. A feet on the condition. large section of terminal ileum, caecum, We have had a number of cases of and ascending colon was removed. The this functional type under observation patient made an uneventful surgical showing many and varied symptoms recovery and much to the surprise of which have been benefited by eliminat- the parents and the physicians he re- ing the foci of infection. In a great mained perfectly quiet in bed and was many of these cases the most import- no trouble to the nurse. His constipa- ant lesion was in the lower intestinal tion ceased. In the course of a few tract and a resection of the colon was months he began to show marked im- necessary to eliminate this infection. provement in his conduct. He was not Another case is of sufficient import- so restless, and his activities became ance to report her©. The patient was '^ore purposeful in type. The following a boy six years old who had been nor- spring he was able to enter school. He mal until two years old. He then be- has been seen on several occasions, the came very restless and unmanageable last time November, 1920- His mother so that his mother could not allow him reported that he reacted in a normal out of her sight. As he grew older manner to his surroundings, showing these symptoms became more marked, none of the peculiar conduct which he At the age of two he also developed had before the operation. He attended convulsions which occurred every two school regularly and his teacher report- or three months, but these did not get ed that he had no difficulty in learn- any worse. He was sent to school but i^S- he was unable to remain. He made no Although this case is not reported effort to learn and could not be made primarily on account of convulsions it to obey. He caused so much disturb- is also interesting to note that he has ance that he had to be taken from had no convulsions since the operation, school. He was not vicious, but in- As two years have elapsed since the clined to be destructive and was very operation we feel justified in consider- silly in his behavior. When seen by the ing that the removal of the infectious writer he showed marked hyperactivity toxic factors in this case has been suc- of a purposeless type. He moved every- cessful in changing a feeble-minded in- thing about the desk and if his mother corrigible boy into a normal one. relaxed her attention he was into all A third case bearing upon this prob- sorts of mischief. A thorough exami- lem is as follows: A boy eight years nation revealed the fact that he had a old had had chronic constipation since August, 1922 ORIGINAL COMMUNICATIONS 397 i; Taney, never having had a proper bowel movement without taking strong purgatives. Had had so-called "bilious attacks" all his life and his mother de- voted as much time as she could spare to the preparation of special foods and dishes, as it was only by so doing that he could be persuaded to eat at all. He had four brothers and sisters, all ro- bust, normal children, but he quarrelled with them constantly. He was distinct- ly the "odd" and defective member of a family otherwise entirely normal in every respect. As time went on, de- spite the mother's efforts, from being thin he became emaciated, complained of constant headache, increasing consti- pation and backache. His temper, al- ways bad, grew to be intolerable; he flew into violent rages without cause or became moody, sulky and depressed. In spite of his youth he was suicidal, being afraid to go in a rowboat lest he throw himself overboard. Finally in a fit of uncontrollable rage he tried to shoot his father with an air-gun- X-ray revealed a six-day delay in the right colon. The right side of the ab- domen was tender and rigid. When the parents were told that an operation car- ried with it no definite promise of im- provement, they replied that any risk was justifiable as the child's condition seemed to them hopeless. At operation the impaired part of the bowel was found to be confined to a relatively short partially obstructed segment, which was removed. This was done January 6, 1920. Result January 6, 1921 : Gain in weight, fifteen pounds. Surgical cure of constipation. No medicine since operation. Is working hard and success- fully at school. Temper, appetite and general behavior that of a normal child. Now no different from his broth- ers and sisters. These three cases are cited to show that an investigation of the individual for pathological conditions existing out- side of the brain is imperative, and will often lead to the discovery of causes, the importance of which was unknown and which formerly appeared to have no re- lation to the mental defect. Just what proportion of defective children of the functional type are amenable to treat- ment cannot at present be stated, but enough work has been done to justify the conclusion that many of these so- called feeble-minded individuals have physical troubles and are retarded, not so much by lack of development of the brain, as through the action of various toxins and the resulting disturbances of the cellular metabolism. The Juvenile Delinquent. Many of the juvenile delinquents can be classed as abnormal mentally. At least 60 per cent, in thie various reform schools can be classed as normal men- tally, but the delinquency has arisen from environmental causes such as lack of proper home training, influence of bad companions, and opportunity for petty misdemeanors. When these types are sent to reform institutions they usu- ally recognize their errors of conduct and react to institutional discipline. They benefit by training and after they remain sufficiently long in the institu- tion they are paroled and under good influences become upright and useful cit- izens. This class constitutes about 60 per cent, of the cases found in the insti- tutions for delinquents. The remaining 40 per cent, should be grouped as men- tally abnormal as well as subnormal. They may have had bad environmental influences similar to the first group, or, as frequently the case, they come from families where they have received the best training and yet become delinquent. This group presents an entirely diflfer- ent problem from those in the first group. They apparently do not know right from wrong, show no remorse for their actions and do not react in a nor- mal way to discipline. They have little self-control, continually break the rules of the institution, and have to be con- stantly punished for these infractions. They frequently show marked emotional instability, become hysterical for very inadequate reasons and impossible to manage. In extreme cases they are apt to destroy furniture, and clothing, and materially upset the discipline of such institutions. 398 SOUTHERN MEDICINE AND SURGERY August, 1922 Whether these types are in the reform Conclusions, schools or training schools for feeble- ^j^jj^ ^^^^ record is not conclusive, at minded they present a purely medical ^^^ ^^^^ ^.^^ ^^ ^^^^.^^^ ^^^^ ^^^y problem. In other words they are hos- ^^ ^^^^^ so-called defectives and delin- pital cases and not institutional. They quents can be accounted for on the basis should be treated in a hospital rather ^f toxemia similar to that found in the than custodial institution. psychoses. It is true that many of these We have had the opportunity to exam- cannot be classed as insane. The con- ine all the persons committed to the stitutional reaction to toxemia is appar- State Home for Girls, the Rahway Re- ently different and is analogous to v^hat formatory for Boys, and other juvenile we find in alcoholic cases. Many indi- institutions in the state. Many of these viduals who indulge in alcohol do not cases have been transferred to the State become insane in the true sense of the Hospital which acts as a clearing house word and could hardly be committed to as there is no other institution which can the State Hospital, but they show mark- make the proper study of them. A thor- ed change in disposition and conduct, ough examination has revealed many ab- They lose their moral sense, their busi- normal physical conditions; practically ness ability suffers and they decline in all of them have impacted molars and the productive scale. Other cases show other teeth and frequently infected teeth a distinct psychosis and can be classed besides. All of them have infected ton- as insane. sils. A certain number show involve- What has been said here applies par- ment of the gastro-intestinal tract, and ticularly to the pseudo-defectives but not in the females infected cervices are com- congenital types, for it is evident that mon. those who are born defective cannot be In the last year twenty-eight girls improved by treatment, but undoubtedly from the State Home have been admitted there are many cases who are considered to the hospital, usually as voluntary ad- defective in which the factors are largely missions; eleven have been discharged acquired and these offer a fruitful field as recovered, nine are still in the hos- for investigation and treatment, pital, and seven had to be finally trans- We should not leave out of considera- ferred to other institutions. From the tion the role of the glands of internal Training School for Defective Women secretion in many of these cases, but fre- at Vineland we have received thirteen quently the trouble will be found in patients ; ten are still in the hospital and chronic foci of infection and if these three have been discharged. From the foci are removed the disturbance of the State Home for Boys at Jamesburg, glands of internal secretion will disap- seven cases have been admitted ; four are pear. As a result of our work, which, as still in the hospital and three have been I have stated, while not conclusive, we discharged. From the Rahway Reform- would make a plea to those engaged in atory, fifteen cases have been admitted ; this very important work that the indi- four are still in the hospital and eleven vidual be considered as a whole and that have been discharged. From the State wherever possible all chronic foci of in- Prison, fifty-nine cases have been admit- fection should be removed. Of course, ted ; forty-nine are still here and ten this in no way should interfere with the have recovered and have been dis- proper education and training so neces- charged. sary in these cases. August, 1922 ORIGINAI. COMMUNICATIONS 399 indicated not only by these instances but DIAGNOSTIC SURVEY BY DIAG- by a rapidly growing literature, the etio- logic role of focal infections is being NOSTIC COMMISSIONS FOR ^,g^y generally recognized and acted ASYLUM POPULATIONS. upon— everywhere except among the classes in which they are productive of By Charles A. L. Reed. A.M.. M.D., F.A.C.S.. the most tragic results. I allude to the Cincinnati, Ohio. epileptics and insane now incarcerated consultant to the Cincinnati General Hosptal; in the asvlums of the country-the WOrd former President American Medical Asso- asylum being USed to designate a purely elation and of the Academy of Medicine. custodial institution as distinguished from a hospital which is a curative insti- The relation of focal infections to the tution. I desire also to make clear that cause, pathology and rational treatment y^j-y generally, the responsibilty for this of so-called epileptics and the equally condition in the asylums is due to the so-called insane, is of increasing interest "system" and not to the indifference or if not imperative importance. Thus, incapacity of their medical officers, during the last eleven years, I have Fundamental Facts and Their found focal infection present in all of Significance. more than one thousand consecutive The experiences of Dr. Cotton among cases of "epilepsy," otherwise more the "insane" and of myself among "epi- properly called chronic convulsive tox- leptics" are parallel in several important emia. Thus, again, during the last four particulars. Thus, (1) all cases — all! — years, at the New Jersey State Hospital, as determined by physical and X-ray ex- Dr. Henry A. Cotton has found focal in- aminations, have splanchnoptosis; (2) fections constantly present in certain all cases— all!— that have been subjected forms of "insanity," otherwise more to surgical exploration, have had focal properly called chronic psychotic tox- infection of the intestinal tract associ- emia. A distinguished neurologist. Dr. ated with visceral displacements and Herman H. Hoppe, has just reported to bacterial involvement of the mesenteric me of a case in which he had clinically and mesocolic lymphatics ; (3) other foci demonstrated that a focus of infection in occur in order of frequency, in the teeth, the frontal sinus had been the cause of tonsils and accessory sinuses; (4) still a confusional insanity. In the practice other foci occur occasionally in the gen- of the same distinguished neurologist, ito-uinary organs of both sexes and in some six or eight years ago, infection of other organs and structures. The con- the colon was similarly demonstrated to stant occurrence of intestinal infections have been the cause of a simple melan- in these cases is explained by the fact cholia that had kept a useful lawyer in- that they may occur independently of carcerated in a sanatorium for three any other focalized infection ; that they years and that cleared up in three weeks always exist in presence of foci in the after the underlying condition had been teeth, tonsils and sinuses ; and that they surgically corrected by an operation at often persist after all other foci in teeth, my own hands. An eminent internist, tonsils, sinuses and elsewhere, are elim- Professor Martin H. Fischer, but re- inated. The observations of Dr. Cotton cently had a case of acute manacal dis- and myself further agree in the par- turbance to clear up following the re- ticular that, as shown by histories given, moval of painless apical abscess involv- these foci, or some of them, wherever ing but a single tooth. Multitudes of located, are antecedent to the convulsive, similar instances could be recounted psychotic or other toxic phenomena. The from these and other equally reliable relationship of cause and effect is there- sources. Those here given are cited only fore logically inferred. The demands of to illustrate the rapidly broadening ex- the law of cause and effect are, however, perience of the general profession in all further satisfied by the fact that, in parts of the country. In other words, as n.any of these cases, the removal of the SOUTHERN MEDICINE AND SURGERY August, 1922 cause has resulted in the subsidence of the effect — or, in other words, in the cure of the patients. These observed and amply substantiated facts relate to the welfare of hundreds of thousands of "epileptics" and "insane" in asylums; to the welfare of as many more who ought to have active treatment; to the happiness of their millions of relatives and friends; to the many millions of dollars loss, economic and direct, incur- red by the state. The possible signifi- cance of the great underlying truth is, therefore, so profound that the problem, viewed from this angle alone, ought to be neither ignored or deferred by either the profession or the public. Independent Diagnostic Surveys. The etiologic and pathologic findings just recorded, while amply confirmed by incidental cases at the hands of various practitioners, by at least one large insti- tution and, in a more or less desultory way, by various other institutions, yet rest essentially upon my own experience of eleven years confirmed by that of Dr. Cotton covering at least four years. To both Dr. Cotton and myself our experi- ences, severally or jointly considered, are conclusive. There are many mem- bers of the profession who maintain our views. There are, however, others, es- pecially those who were taught the older doctrines, who are honestly incredulous. There are still others who, without con- sidering the facts for a moment, turn from them and their deep significance with resentment if not actual hostility. I consider it unfortunate that some of this latter class are in charge of institu- tions that control the welfare and des- tinies of many thousand patients of the type under consideration. But in view of the fact that they do occupy such posi- tions and in view of the great human interests at stake, I urge that it is of the highest importance that the fundamen- tal scientific facts of causation and path- ology should at once be put to the most crucial test. This is the basis for such a tions to be made by the most modern sci- ditions in a similar or larger consecutive number of certain types of "insanity," logically the same findings must be pos- sible in any other thousand consecutive cases of "epilepsy" or in any other thou- sand or more consecutive cases of sim- ilar types of "insanity." This fact points not only to the practicability but to the importance of independent, thorough and comprehensive diagnostic surveys of asylum populations. Such surveys along the lines of focal infections, even if confined to a few institutions would tend either still further to confirm or to disprove the findings and conclusions of Dr. Cotton and myself. But, while ask- ing for the most rigid determination of facts, this suggestion is not offered in a spirit of banter or controversy but solely in one of constructive co-opera- tion with progressive medical officers of these institutions. The sole objectve should be to determine the incidence of focal infections among "epileptics" and the "insane." How many have infected and poison-producing teeth or jaws? How many have similarly diseased ton- sils? How many have suppurating sin- uses? How many have displaced and consequently infected intestines? How many have foci of infection in other or- gans or structures? How many have actually infected blood streams? To what extent have there developed sec- ondary foci in other organs and struc- tures? Diagnostic Commissions. Diagnoses in asylums now are made by the staffs of the respective institu- tions. They may be classified as neuro- logic or psychiatric or neuro-psychiatric, or psychoanalytic. Only rarely if at all do they embrace a careful appraisement of phenomena connected with what are called the mind and nervous system. What is here insisted upon is that, in every case, there shall be a highly spe- cialized diagnosis of every possible phys- ical and clinical feature, all determina- test: If I have found focal infections with associated definite pathology in one thousand consecutive cases of "epilepsy" and if Dr. Cotton has found similar con- entific methods. Among modern scien- tific methods of diagnosis none has been more definitely evolved than the group ctudy of cases. The newer knowledge August, 1922 ORIGIN. \ I. COMMUNICATIONS 401 with respect to focal infections, with its would squeeze pus from one or more revolutionizing influence on all medical crypts; others have come with the as- science, more than any other one thing, surance that the X-rays revealed normal has forced the development of group teeth when a properly secured film show- practice. In no branch of scientific prac- ed apical abscesses at from one to a tice, diagnostic or therapeutic, is group dozen different teeth; others in which co-operation so imperatively demanded the abdominal viscera, X-rayed with the and so thoroughlv impossible as in the patient always prone, was reported nor- existing generally prevalent system of mal when one picture taken with the pa- asylum treatment of "epileptics" and the tient erect at the time the barium was "insane." The whole situation would ingested ; another, taken six hours later, seem, therefore, to call for the appoint- with the patient prone ; and another ment of a group made up of certain spe- taken after twenty-four hours with the cialists to act for the present as a com- patient erect, demonstrated extreme mission to conduct a diagnostic survey gastro-coloptosis with fecal stasis due to of an institution or institutions under ileal bands and to retardative angula- the control of the state. It ought first to tions. These conditions always imply to be provided with ample physical facili- the observer familiar with living pathol- ties— a generiil analytic laboratory, a ogy of the abdominal viscera, certain bacteriology, roentgenology, dentistry, other definite invariable conditions, laryngology, ophthalmology, with an ab- namely, infection of the intestmal folli- dominal surgeon and an internist to con- cles, infection with enlargement of the duct the general physical examinations lymphatics and venous stasis of the mes- and to interpret and correlate the find- enteric c'rculation. These instances are ing of the technical specialties. Of cited to show the importance of first, an course, as neurologists comprise the staff adequate diagnostic equipment; second, of the institution, a neurologist would a correct diagnostic technique in deter- not be on the commission, the verv object mining the underlying physical facts; of which would be constructively to third, a proper appraisement of then- check up the neurological diagnosis al- clmical values when, fourth, they are in- ready made. Then, too, as all medical terpreted by persons practically familiar officers of these institutions must either with the living conditions to which they favor or oppose the whole diagnostic relate. The appointment of diagnostic movement they deserve to be spared commissions would, furthermore, insure from the equivocal position of determin- the actual use of adequate equipments ing facts that relate to their preconcep- which, it is known, have been generously tions. practices or possible personal in- furnished to more than one institution terests. The functions of such a com- but in which no general diagnostic sur- mission would be purely diagnostic and veys such as here outlined, have ever its tenure would end with the completion been so much as attempted, of the diagnostic survey. The Economic Phase. r^i; ■ , -(r 1 Jr.- ^- It seems almost a disgrace that where Llinical values (ma Diagnostic , -j. -l, ^•4^ i i, „uv, ^^ ^rViof humanity, where life and health or what Interpretations. jg ^^^^ precious than either, sanity, are One motive for the appointment of in- concerned it should be necessary to quib- dependent diagnostic commissions is to ble about the chips and whetstones of secure for the patients not only the cost and profit. In the last analysis, highest technical skill available but ex- however, money becomes the measure of aminations by methods calculated to re- values and it is therefore necessary to veal rather than to conceal the truth as take it into account in connection with to their exact condition. Thus, for in- the proposal for diagnostic commissions, stance, I have had cases referred to me Of course the members of each comm^'s- with the statement that there was noth- sion must be paid and to secure the ing the matter with the tonsils when a nroper service, they ought to be reason- little pressure with a laryngeal mirror ably well paid. But the medical profes- 402 SOUTHERN MEDICINE AND SURGERY August, 1922 sion has always been ready to make sac- ready given show that on the average rifices for the public good and would there are about three of these cases to probably do so in the present instance, every general practitioner in the United This being true probably from $10,000 States. They occur about equally in to $12,000 would secure the services of every section, in every neighborhood. a corps of experts for a period of from The institutions are crowded and their six weeks to two months to make a diag- medical officers, many of them of the nostic survey of an institution of ap- most progressive type, are appealing for proximately fifteen hundred inmates, such change in the "system" that they Laboratory and X-ray equipments will can do something actually curative for cost about $25,000 or a little over $6.00 their cases. In the circumstances each per capita. On this basis, at the New member of the medical profession is ask- Jersey State Hospital, an institution of ed to use his or her influence with 800 admissions annually, the resulting asylum directors, state charity commis- savings on maintenance of patients alone sions, legislatures, and governors, to se- has been estimated at $90,000 per year, cure the equipment and personnel neces- A conservative estimate, based upon the sary to give these unfortunate classes findings of the National Commission for the benefit of the latest and best develop- Mental Hygiene as to the number of in- ment of science in determining the fun- sane in asylums, indicates that in such damental facts of their illness, institutions and in alms houses and re- formatories, there are more than 335,- 000 — a third of a million — insane in the United States who are receiving public THE VALUE OF PSYCHOANALYSIS aid. Add to this 14,937 epileptics and tO THE GENERAL PRAC- 40,159 "defectives" in institutions a year ago, and add to all the increase in each TITIONER.* class for the year and it will be seen that the public is today supporting in excess of 400,000 persons in what, with but a Psychoanalysis has truly come into its few honorable exceptions, are purely ^wn. Indeed, it has even overshot the custodial institutions. These figures, on ^^rk it set for itself, fo no longer is the basis of savings at the New Jersey the application of its principles confined institution, show possible savings for to the limits set down by abnormal psy- the entire country of $18,000,000. And chology-broad as these are-but its in- this is on maintenance alone, no account terpretations have ramified until today being taken of the economic value of pro- they are applied to art, pedagogy, and ductive energy restored to the commu- the everyday affairs of life. We hear mty by recoveries. Of course while con- this young but vigorous science discuss- sidermg economics 1 would be sentimen- ed in the medical society, the college tal If not silly to allude to the restored ^ass room, in popular magazines, in happiness of thousands of now bastiles drawing-rooms, and on the street. Psy- mma es and to the .loy of their millions choanalysis has become a universal phi- of relatives and friends. l^^^pj^y ^^ ^jl ^^^^^ undertakings. An Appeal. But such success might be said to be This article is written as an appeal to characteristic of many isms and cults the general medical profession for co- which, mushroom-like, shoot into favor operation in securing the diagnostic Quite suddenly every now and again only survey of asylum populations. There is to wilt and die when time proves their probably no one subject that appeals in claims and merits to be exaggerated, if a practcal and humanitarian way to so not deliberately fraudulent. In psycho- large a number of general practitioners as does the care of epileptics, the insane * ^'"'"'^ '''^^°'"*^ "''' Tri-state Med>:ii Associa- cr,^ oco^«,-„4- ^ 1 ^ ^' ^"^'^"^ tion of the Carolinas and Virginia, Norfolk, Va., and associated classes. The figures al- February 22-23, 1922. By Louis E. Bisch, MD., Ph.D., Asheville, N. C. August, 1922 SOUTHERN MEDK INK AM) SLKCERY 403 analysis though, we are not dealing with cine, then, indeed, an understanding of a short-cut, fanciful therapy, built out of psychoanalysis must be an asset to every thin air and with little more to its credit physician, whether that physician be a than a new and more novel method of neurologist, an internist or a surgeon, suggestion. In psychoanalysis we sim- However, perhaps but few realize the ply have an extension of psychological importance of the mental side in every principles to include an understanding of case outside of specific disorders of the functional diseases hitherto left unex- central nervous system. Perhaps^^^^ fail plained or at best, explained and treated to realize the significance that the mind by empirical methods of hit and miss plays in disorders of other organs be- that recorded more failures than cures, sides the brain. Psychoanalysis is not hypnotism, it is a That which we do on purpose, know- direct antithesis of it. Analysis is built ingly, we can do more effectively. What upon a logical sequence of cause and ef- are some of the benefits that one may feet which the patient must not only gather from the doctrines of psycho- understand intellectually, but must in analys-'s in this connection? addition feel emotionally, to be true. i do not believe I am overstating it The principles underlying psycho- when I say that every disease, no matter analysis add such wonderful insight into what its cause, has some mental corre- the workings of the mind that the older late that may need attention— at least laboratory psycholog>' which dealt al- sympathetic understanding. Psycho- most wholly with mental output alone analytic principles are not applicable to appears to be superceded and out of the direct treatment of pneumonia, date. Analysis differs from ordinary psy- typhoid, or any other germ disease, nor chology in that it concerns itself not so do they attempt to cure such organic much with what a patient thinks or does disturbances as heart, lung, or kidney as with the reasons or causes why his be- disease. Nevertheless, we all know that havior is such as it is. Analysis embod- the brain is the great sensitizer of the ies an expansion of the doctrine of Soc- ent're body and that organic pathology rates to "Know Thyself." It is a system may affect the mind in many ways that of mental search that requires long, la- we should take note of in our general borious hours of painstaking work. therapy. Neglecting the mental side ot The reason why the general practi- a case may be just the one factor that tioner should find mental analysis not thwarts us in accomplishing a cure. Fail- only interesting but of practical value ure to study the character make-up of as well, is : First, because the physician our patient may be responsible for a pro- in general medicine comes into direct longed period of convalescence that even- contact with human nature and receives tually produces an ailing, sensitive, in- an insight into the affairs and ways of trospective chronic, man as few are privileged to do ; sefc- I am reminded of an internist in New ondly, the doctor is the natural counselor York city who, whenever his turn came of hundreds of people who would hesi- as a visiting physician to one of the larg- tate to expose their strivings, disappoint- est hospitals there, made it a rule to ments and sufferings to anyone else; wheel all the old typhoid cases out on thirdly, it is the physician who makes the porches into the sunshine. Then he the first diagnoses and classifies the case would begin feeding them up on meat, for possible treatment by the specialist ; The majority of the patients improved at and lastly, but perhaps most important once. They had become "hipped" on of all, the general practitioner must of their disease, so to speak. Attention to necessity employ daily some of the most the mental side worked like a charm, fundamental of the concepts included in Again, take chronic diseases, like pul- the psychoanalytic system. mcnary tuberculosis, of which one sees If the human element is an equation a great deal in Asheville. Many a pa- to be dealt with in the practice of medi- tient would linger on, "taking the cure, ' 404 ORIGINAL COMMUNICATIONS August, 1922 long after it is necessary, were he per- It has been found that it is easier to mitted to follow a natural inclination, bring back into consciousness things that The rules of hygiene and rational living originally were pleasurable in nature laid down for him may very easly be- while it is often difficult, nay sometimes come an obsession — a "fixed idea" — so impossible, to remember experiences that he gradually develops a highly self- that had some unpleasant emotion con- protective manner of living, no longer nected with them. When anything dis- necessary, and decidedly banal in its in- agreeable happens consciousness pushes fluence on his future. Here the wise it out of the way — submerges it into the physician with foresight prevents an unconscious — as quickly as possible. If economic wreck — not to mention the in- consciousness did not possess such a self- dividual's own unhappiness and ineffi- protective device we would continually ciency — by helpful, stimulating counsel, be harassed by the manifold disappoint- At the present time our Public Health ments wh'ch come to us all and would be Service Hospitals harbor scores of men prevented, because of such nagging who have never done a stroke of work worry, from thinking or doing anything since the war because they are afraid of else. This ability to submerge into the themselves and rendered helpless by fan- unconscious memory storehouse is, ciful ideas of self-depreciation. Only therefore, a very valuable attribute of last week I saw a patient with a stiff the human mind. back and a grouch against all society be- The psychoanalytic term for these cause he believes the lumbar punctures submergings is repression. performed on him for suspected menin- Everybody has repressions of one kind gitis while m camp have ruined his life, or another and the person who is sick is And, I must hasten to add, such men likely to have certain very important are not malingering. They are truly ones. No one wants to be sick — unless, sick. But the mental correlates which perchance, we are dealing with hyster- we see as the aftermath of acute illness ical states, and even here the patient's were allowed to heap up because, in the desire to be ill is not conscious — and majority of cases, in the hurry and bus- every sick person is bound to accept the tie attendant upon the war, the mental inevitable and is compelled to make, of- side had to be neglected. ten quite suddenly, adjustments to the A short paper, such as this, cannot, of new situation which he has to meet. A course, give even an outline of so com- sick man gives up his work, a woman her prehensive a subject as psychoanalysis, household duties each is made to live a Suffice it to say that the chief mental life entirely different from what has mechanisms I wish to touch upon are re- been the custom and none of which is pressions, transference, resistance, and pleasant. Added to this is the suffering conversion symptoms. from malaise. The net result is repres- For purposes of clearness we must ac- ^^^^' cept the premise that we possess an un- Furthermore, whether well or ill, all conscious or subconscious as well as a of us have an unconscious fear of death, conscious mind. The conscious mind is We may not consciously realize it but the intermediary, the means of commu- the proof of its existence is the fact that nication, between the outside world and we save in order to provide for our fam- the unconscious, which is the storehouse ^^i^s, we buy life insurance and draw up of all our mental images. Every thought, wills, and finally, but most important of action and experience from the cradle up ^1^' ^e adopt some religious concept is tucked away in an orderly fashion in which we believe will tend to safeguard this unconscious mind. Disagreeable as "» for an hereafter, a thought whicli well as pleasurable experiences are hid- comforts us that death will not actually den away there ready to be recalled by mean the end of everything. If death is consciousness — remembered, as we say one of those unpleasant ideas that even — when occasion demands. healthy individuals tend to push away — August, 1922 SOUTHERN MEDICINE AND SURGERY 405 to repress — how much more tangible and ter in the fancies, aspirations and near does this fear become when stricken dreams of childhood days. All our day with disease. dreams and night dreams show these in- The patient believes that his doctor fantile traits. Being a child again— will spare him from death. It is to the feeling, acting and thinking like a child physician that the patient looks for guid- —is invariably the line of least resist- ance, help and consolation. Therefore ance. with every dose of medicine there should The child loves its father and mother ; go a measure of reassurance calculated is dominated by their influence; cher- to bring about that feeling of safety ishes their memory. When stricken with without which no practitioner can sue- illness nothing is so comforting as the ceed as well as he might. hand that rocked the cradle. We all know of colleagues in whom The physician occupies the same rela- patients have unbounded confidence al- ^'^e position to the patient that the fa- though their skill and knowledge of mod- ^her does to his child. The doctor is a ern medicine are not of the highest or- second father and, like the conception der. Why is it they succeed so well— ^f the holy father and the priest of the that often they succeed when others p^tholic Church, he stands as the un- have failed— that they often carry pa- ^^ilmg triend, the counsellor and guide, tients through hazardous illnesses to The father shields from harm; so does complete recovery? Largely because the doctor. The father is self-sacrific- they do not look upon a patient merely i"^ ^"^ altruistic; so is the doctor. The as a case-an obiect to pill and diet— ^^^her and the doctor have identical at- but besides their treatment of the dis- tributes in the mind of the patient, ease as such these doctors add a human I" ^ paper that uses the word "value ' element, a comprehension of the person- ^" '^^ ^^^le one may justly expect certain alitv side, that the patient at once recog- Practical rules of procedure that would nizes and appreciates. ^^^ o"^ m handling the mental side of This communicating band of sympa- a case, in efi'ecting transference. Unfor- tunately, I can off'er no rule of thumb thetic understanding between physician methods to this end. No two individuals and patient-this rapport -is an ex- ^^,^ alike; no two patients can be spoken ample of what psychoanalysts call trans- . • .■> tt^ u ^- ^ • £ ii7-ii- ^x r i.1 to in the same way. Each patient is a lerence. Without transference the men- - , • • j- -j / i i » i^-v, t. , , . , » . . • , . study in individual psychology. Although tal side of a case is certain to be neg- r n , , ,• .r.t. j.-^.- , , , T J J -^ ^ 1- X- I firmly believe that every practitioner lected. Indeed, an opposite feeling ol ,-, /,, . ui i. u u „ , . ' ^^ n- 4.U would profit immeasurably should he so-called resistance may result, the pa study the principles underlying psycho- even a more tient being not merely indifferent to the ^^^j^^j^ j ^j^^ ^^^j ^^^^ ^_^ ^ _^ I3hysician and his treatment but definite- thoughtful, studied approach in dealing ly opposed and stubborn to any influ- ^^.^^ ^^^ ^^^.^^^ personalities that the ence emanating from him. practitioner meets, would be superior If psychoanalysis has taught us any- ^nd vastly more successful than the off- thing at all. It has demonstrated how in- hand, haphazard manner in which med- fantile our true, inner, unconscious j^al science is altogether too often ap- selves really are. Men and women are pijed. little more than grown-up children. The Were this not true Christian Science, characteristics developed during the Qsteopathv, Chiropractic and all sorts of earliest years lay the foundation for our curious sects and fakes would not flour- entire subsequent lives. In the neuroses jgh as they do. The average individual —the functional nervous disorders— one first passes through the hands of a med- can demonstrate how these individuals i^al practitioner before he transfers to when wosted in the conflict of life, the faith-healer. If he has lost his con- when unable to harmonize their striv- fidence in the M.D. there must be a rea- ings with the cold, hard world of reality gon. I fear the reason is not far to seek, about them, turn their backs to find shel- It lies primarily in an attitude on the 406 ORIGINAL COMMUNICATIONS August, 1922 part of many doctors, even today, that sis to be of psychological origin. If such either a mental side to disease does not be the case direct treatment of the or- exist or that, whatever it may be, it is ganic side involved is futile, some queer idiosyncrasy, or freak of the I do not wish to leave the impression imagination, or lack of will power, or that all organic disorders may have a some r'h?r fool thing that the physician causative basis that is mental. I only cannot take the time to bother with. wish to emphasize that some may, also Psycholanalysis teaches us that noth- that all organic diseases have certain ing is foolish, trivial or nonsensical that psychological correlates which it may be flows from the mind. It teaches us to highly important to recognize and treat be patient and forbearing. It teaches if complete and lasting recovery is to be us that every result is antedated by a hoped for. cause and, although the result may ap- If the general practitioner were sys- pear to be far-fetched, illogical and un- tematically to take a thoroughly corn- founded, the cause, when discovered, plete history in each case he would often may prove invaluable for our further discover at the outset what the psycho- treatment, logical background is. We fail less often Psychoanalysis often interprets what because of ignorance than we do because are known as conversions. These are of lack of care. Peculiarities of beha- common in the neuroses. By conversion vior in childhood are always significant, is meant a physical symptom which is Emotional shocks may have a bearing caused by unconscious mental repres- on the case, sion. No psychoanalysis should ever be at- I shall here quote from Dr. Wm. A. tempted until all physical pathology has White's "Principles of Mental Hy- been ruled out. But organic therapy gigj^g". should not be continued indefinitely ''To 'show the immense practical im- I'^^Z'^^i^^intt^^^^^^^^ '' ' ?iew rLfe leLrdLtr^t^kL^^tm . ^ ^^ ^- ^^^^ed- of psychoanaly- the recent literature, which were found '^' ^'^" P^^f.*^ ^^ of practical value to to be mental in origin although for the '^'7 practitioner. There is nothing most Dart thevwPrpannarentlvT^hvsieal "^^stenous or occult about psychoana- most part tney.^ ere apparently physical J principles. As William James I think it will be admitted that many of ^- -. . V „, „• , ,,j. . ^. ° these ailments would be apt at least to ^'^^l^r^ '^'^- ^^ '' Pragmatic-it be treated by other than psychological methods. This list includes many forms Discussion of asthma, sore throat, difficult nasal T^ t » tt j -r^- , i tt breathing, stammering, headache, neu- ^^- ^- ^' ^""^^^^^ Richmond, Va. rasthenia, backache, tender spine, "weak I think this subject is a very impor- heart," fainting attacks, exophthalmic tant one, especially to the general prac- goitre, aphonia, spasmodic sneezing, titioner, and, incidentally, to the special- hiccough, rapid respiration, hay fever, ist ; but I believe that it is right that as gastro-intestinal disturbance (constipa- far as possible, we should have sane tion, diarrhoea, indigestion, colitis, gas- ideas of exactly what psychoanalysis is. trie ulcer), ptosis of kidney, diabetes, I was much interested in the enter- disturbances of urination (polyuria, in- taining paper by Dr. Bisch, but he failed continence, precipitance) , menstrual to state to you one principle, one basic disorders, auto-intoxication (from long principle of psychoanalysis, that unless continued digestive disturbances), nu- it is acted upon, the one who attempts to tritional disorders of skin, teeth, hair, use it as a therapeutic measure must etc. The list might be indefinitely pro- fail; that essential fact is this — that lon^red." there shall be no anatomical lesion As Dr. White goes on to say, disorders present- such as these may prove by mental analy- I cannot agree with the quotations August, 1922 SOUTHERN MEDICINE AND SURGERY 407 that were made here as to the efficacy least, very frequently overlook this very of this method of therapy in certain fact. structural diseases; I cannot see when Take for instance the chiropractic, there is a case that is organic, that pro- They magnify that fact, instead of sub- duces certain definite irritative or de- ordinating it, as we do in our practice; structive symptoms how the elimination take the homeopath, he magnifies the of some of these, that are merely re- attitude and treatment of the patient, Hex, can effect a cure. we subordinate it in our practice. I believe there are a great many er- In other words, we have made, as rors in this line of thought. I sincere- Dr- Thompson has called attention to, ly believe there is a great deal, also, in no direct personal appeal to that pa- sychoanalysis, but the errors are quite tient. It is unquestionably true that as many, in my mind, as the verities of there is a large majority of patients who this kind of therapy. I believe too many are suffering from repressions down in men who have followed it have gone the cellars and basements of their minds into faddism over it, and for that very that frequently come up into conscious- reason have claimed certain things that ness and give trouble. When a patient are impossible. becomes weak and disabled physically in We cannot all agree with a great any way, that repression pops up again many of the claims that are made, but and gives trouble. there are certain basic principles under- We don't study our patient enough to lying the whole thing that are of the know it, but I wish to say this, that in greatest importance to every practition- my experience very few patients are er, and, if I may say briefly, that the susceptible to this method per se. I first great benefit is this, that we must don't mean the method of suggestive- treat not only the disease in the patient, ness under which we all live and act but the patient himself. In other words, every day of our lives, but the fact of it matters not what is the matter with simple, absolute psychoanalytical cases, the patient, we must consider the dis- If it is a pure psychoanalytical case, the ease plus the patient in our study of it. raising up through the physician of the Another practical thing that can be obsession or the repression into the day- drawn from this paper is this, that un- light of the conscious mind of the pa- questionably very few of us are as min- tient, this very simple fact, absolutely, utely particular in going into the depths is curative. Explanation and admission of the personal history of cases as we of these repressions to someone else, is should be, for psychoanalysis is really in itself curative. the penetration and explanation of our The case stated by Dr. Thompson was moods, which themselves are largely the a pure psychoanalytical case, and the result of our repressions. I believe that minute that the repression was brought if we were, that we could be able to to the light of consciousness and the draw some differences between cases admission to the husband of this fact, that are applicable to psychoanalytic that patient was cured in a minute, and treatment, and those that are not. I be- only true psychoanalytical cases can be lieve that there are certain people — that cured that way. there are certain temperaments consti- Bear in mind, for fear of making mis- tutionally, if you please, that are indi- takes and confusing the mental condi- vidual to certain patients, and that in tions through which all sick people pass, the study of the application of this ther- this fact : don't take all cases that have apy you must know the individual, the morbid fears or obsessions to be psy- personality of the patient you are treat- choanalytical cases or that can be ing. Psychoanalysis is the analysis of cured by psychoanalytical methods, the individual psychic of the patient at Psychoanalysis as far as it goes in the hand, and until you do that, you cannot cure of disease is worth a great deal. It build upon it. I feel that all of us, at is going to grow, but it must not be ORIGINAL COMMUNICATIONS August, 1922 carried by its disciples into the realm of faddism. Anyhow, I want to say this, that I believe that this class of patients of whom I am speaking can be divided ab- solutely into the psychogenetic cases. There are certain people who are so tender, so susceptible to every impres- sion on earth, that they are more sensi- tive to these conditions. Their psyche is a peculiar condition, and they suffer from this psychic condition. It is this class of people that are cured by psy- choanalysis. There are some people that are hypnotic in a suggestive way, be- cause they are abnormal mental pa- tients, by birth and from the very be- ginning. While there is a great deal in these cases for the practical benefit of all of us, the second lesson to be learned is to treat not only the patient but to treat the patient plus the disease, and study the patient to see if there is an indi- vidual psyche in that patient that may be influenced by sympathy, and by a complete revelation of something within them that has been repressed for some time. Any man that can go back and trace through an obsession of dreams, day and night dreams, and in these find basic sexual impulses that have origi- nated or intensified their physical status, as well as mental, through 40 or 50 years of life, have carried it to an excess that I don't think attainable, but there is a good deal in it to make us study ourserves, and study our pa- tients. Dr. Tom A. Williams, Washington, D. C- A great deal of adverse criticism has been launched against psychoanalysis — scarcely against the kind of psycho- analysis spoken of by Dr. Bisch. To the word "psychoanalysis" has been attached various specific meanings; for instance, the kind of psychoanalysis nracticed by Dr. Freud, of Vienna. Dr. Bi~'"h has left out some of the essential contentions of that doctor. True psychological analysis or explo- ration, as I prefer to call it, is simply applying to symptoms they c^ll mental the kind of study and search into the cause or meaning which we have long applied to symptoms v/e call physic. For instance, some years ago I had a case, a young mechanic, who had dived into a creek and had a haematomyelia of the spinal cord, which caused paraly- sis of one hand and wasting of the mus- cles. He had done no work for two years- He was sent to me in a vague kind of way for something to be done. Nothing could be done to remove the residual lesion, but I ascertain that this man could use his hand partially and he was not too inefficient to work as a me- chanic. He could learn to work with his left as his principal. He went to work in a week and has stayed at work ever since. That is psychological treatment but it has nothing to do with psycho- analysis. Take another case I published in Vir- ginia Monthly. A well known engineer could not sleep during an attack of some infection. His doctor called me to remove the insomnia. I found out that he had been accustomed as engineer all over the world to "run the job." He was run- ning his own case. He was keeping awake so the nurse would not forget his medicine at the right time. When that was found out, I explained to him that if he was in a subordinate position in an engineering job and was interfering with the boss' job he would think it was very wrong. I said "The boss is the doctor, the foreman is the nurse, and you are only a laborer." I said "You let them take the responsibility of this job." He did, and slept thirty- six hours the first night. You can call that psychoanalysis, if you like, but it does not involve any of the Freudian theories, for the uncon- scious, even though some might claim this man's "unconscious" was controll- ing the situation. It was a habit of mind that had to be detected — dealt with, and no need to invoke a hypotheti- cal "unconscious" existed and state in obscure language an interpretation es- sentially simple. August, 1922 SOUTHERN MEDICINE AND SURGERY 409 Our quarrel is with those who place exclusively the name of psychoanalysis upon certain kinds of theories which we don't believe, one or two of which was mentioned by Dr. Bisch. We who differ have applied the methods of science away from speculative methods to the kind of behavior w^e see in human be- ings who are sick and after that to human beings who are well. It is gene- tic psychology if you will, but not psychoanalysis of the variety espoused by Freud nor that of his apostate Jung, nor that of any American follower. Dr. Cyrus Thompson, Jacksonville, N. C. Mr. President and gentlemen, my friend. Dr. Hall, is exceedingly kind to me, and perhaps just in proportion as he is kind to me he is unkind to you, in that he inflicts me upon you. I sometimes have been credited with the ability to talk well upon things that I know nothing in the world about- I don't know what he wants me to say on this matter. I enjoyed Dr. Bisch's paper. We both live in North Carolina. Somehow or other I haven't had the good fortune to meet him. I want to say to you and to him, however, that he has read a most sensible and also a very beautiful paper here tonight. I shall not hear one that pleases me in every way more than this has pleased me. If I was asked, in this connection, what is the difference between the old- time country practitioner and the newer practitioner, the group-practice man, you know, I should say the difference is in the mental attitude toward the patient. That is, that the old-time prac- tioner considers that his patient is not simply case number so-and-so, but a real human being who calls him in, thinking that the physician is really his friend, and the physician shows himself his friend. When I was over here in December, I heard a little bit of a discussion on the excellence of group practice. I fell into the discussion and I said I lived in a county of six hundred and forty square miles in which there were only six physicians, and that if we all were not of the old sort, we could not get together for group-practice; we could hardly get together for consultation at all; that we were very much like the carpet-bagger who went into Georgia after the war. He was an undesirable citizen. He was treated as a carpet- bagger. Some years afterwards, a hunter came upon a mound that had grown a little old- He found at the head of it a headboard, and looking at it carefully, thought there had been some carving on it. He scraped off the moss and read: "The Yankees came, a murderous band To take from us our Southern land. Behold this alone, secluded spot, It is all that this damned Yankee got." So little could we get of the succulent excellences of group-practice. The old country practitioner (and I am one, and am nearing my three-score and ten, a country practitioner of the old sort) while he does not do group- practice, and perhaps is not so scientific, there is one thing that he has, and that is a heart within him and the human touch. As Carlyle said of Danton in the French Revolution, "He was a man with the heart of a man in him." "I don't want to be brash, but a man that goes out as a group practitioner and considers his patient as a case, body and mind, has not the heart of a man in him. Too often when you go out to them that are sick and felled by disease, unless you have your heart that you can carry along with you, you might just as well stay at home. This is the way an old-timer sees it. There is everything in sympathizing with your patient. If you want to help a man, you have to be sympathetic with him. If you want to help a man, you have to know something of the working of his mind, of what is in his mind — his isolation and separateness from every other thing, his helplessness. Some of you have read "The Garden of Allah." Do you remember the free negro in "The Garden of Allah" who going from his work at eventide went 410 ORIGINAL COMMUNICATIONS August, 1922 on home and sang as he went along "Nobody knows what is in my heart but God and me?" You go to your patients, and especially those that have mental ailments, and nearly all of them have mental ailments, and they have something in their hearts that nobody knows but God and them. If you treat them as a case you will never find out what it is, but if you will get close up and say, "I am your friend and I want to help you ; I must find out everything I can about you ; isn't there something you haven't told me that you can tell me, that I might help you?" You will then make the third person that knows what is in his heart beside him and God- If you don't know him, how in the name of God and common sense, that is human, can you help him ? You can't do it. If I had time, I would relate a case (cries from audience, "Go on, go on!") You talk about psychoanalysis. I know a woman who grew up a wonderfully fine girl. She had been married some three years, and she had in her power- fully the instinct of every good woman, the instinct of maternity. She told me that when she married, she weighed 120 pounds. She had typhoid fever and after that she increased in weight until she weighed in a couple of years 240 pounds. She said "I haven't menstru- ated in ten months, am I pregnant?" She was not pregnant — a case of dys- trophia adiposogenitalis. Incidentally, I remark that I put that woman on thyroid and corpus luteum extracts, and I reduced her weight to 170 pounds and she menstruated again. She was men- struating three months when I lost sight of her. When I heard of her again, I was called to see her and she was "as crazy as a June-bug." She was so crazy that she went to the river to drown herself and got in 100 yards of the river before they overtook and brought her back. I saw her and said, "What is the matter?" She said, "I am so sinful, so sinful." I said, "I never thought you were; tell me about it; how are you so sinful?" She said, "If I could just tell you !" I said, "Tell me." And do you know she told me that as long as she didn't menstruate, she counted that her lack of maternity was due to herself; when she did menstru- ate, the failure was due to her husband ; and when there was no likelihood of motherhood by him, then she was, of her own volition, unfaithful to her hus- band- Then there was no maternity, and her unfruitful sin overwhelmed her and she was absolutely crazy. But when she came and told it to me and to her husband, who did not throw her away, she was as sane and clear as you or I. And God only had known what was in her heart, but when somebody else knew it, and her husband acted with a degree of divine grace and took it quietly, she went on and recovered. That is the work of the old-time phy- sician. It is not the work of laboratory men, it is the work in a way of psycho- analysis, and it is not the work of the group practitioner. "There is nothing in the world like a friend when the world needs a friend." And the terri- blest thing in the world is our ever- lasting individualness. Look at the separateness of the stars and think of our isolated selves, and then the joy of our association. Dr. Bisch Closes Discussion. The time is growing late and our program is behind, yet I feel I do want to say one or two words in closing. Ap- parently my purpose has been accom- plished because all the speakers stressed the fact that we should treat the pa- tient as an individual — that sympathetic understanding is what we need more than anything else. Only those who have actually tried the psychoanalytic method can appre- ciate the full value of this modern viewpoint. Merely to read a few books on the subject — especially those writ- ten by Freud and his immediate dis- ciples— books which, in Continental fashion, tend to overstress sex matters, is bound to leave an unfortunate im- pression- Indeed, there are readers who fix their attention upon the sexual ex- positions cf these treatises to the ex- August, 1922 ORIGINAL COMMUNICATIONS 411 elusion of other valuable psychoanaly- embarrassment that will not be relieved tic material which may be culled from by all the pleasant features of this splen- their pages. In conclusion, I may state did evening and this inspiring occasion, this interesting and perhaps to some, a Your superintendent, mindful of my af- startling fact. I, myself, have treated fection for him, but deluded by the be- both men and women and cured them — lief that I know what I am ignorant of, if the disappearance of symptoms may cordially urged me to speak on this occa- be called a cure — by psychoanalyses in sion about the layman's ignorance of the which sexuality was scarcely touched anti-social tendencies and the criminal upon, in effect not even mentioned. waywardness of certain ones of God's children. How long must one sometimes wait RF^HAVTHR OF THF FFFRT F ^0^ comforting compensation for hard BEHAVIOR OF THE FEEBLE - ^^^ difficult lessons learned in the Sun- MINDED— THE LAYMAN'S IGNO- day-school days of childhood ! The mer- RANrF OF THFIR ANTmoriAT ^st intimation from your good superin- RANCE 0^ THEIR A^lll-bOtlAL tendent that I could find myself able to AND CRIMINAL TENDENCIES. say one enlightening word to you about this obstruse and this profound problem By Jas. K. Hall, M. D., Richmond, Va. relating to the unequal distribution amongst the children of men of the Di- It is pleasant to come again home — to vine Gift — mentality — hurried me back the state of my nativity and to the home along the pathway of memory to the of my fathers. It is inspiring to witness Biblical portrayal of a great coronation, the dedication of these splendid build- "In Gideon the Lord appeared to Solo- ings, and the consecration of their serv- mon in a dream by night : And God said, ices to those children of this common- Ask what I shall give thee. And Solomon wealth of whom the French would speak said, I am but a little child, I know not in the beauty and the tenderness of their how to go out or come in. Give, there- language as the children of the good fore, thy servant an understanding God. Fortune is kind, your Excellency, heart to judge thy people that I may dis- in giving you the headship, even for a cern between good and bad; for who is brief span of time, of this mighty em- able to judge this thy so great people? pire now known as North Carolina. May And the speech pleased the Lord, that I add that the citizenship of the state is Solomon had asked this thing." How fortunate also in having at the head of frequently that prayer must spring from its government one who is so keenly and the heart of His Excellency, and from so sympathetically interested in all the the hearts of all others who are high in people of the whole state. For a period authority and who are laden heavily of almost seven years it was my good with responsibility! How comforting fortune to be permitted to give my serv- and how helpful it is to me this evening ices as a physician to the patients in that to reflect that the mighty Israelitish splendid institution for mental invalids King, endowed with all human knowl- at Morganton, and once and once only edge, confessed in all humility his in- during all those years the Governor of adequacy and his inability to under- tho state came, and then he came in a stand his own people! spirit of destructive criticism. If I should presume to speak to you I am honored in being permitted to about any phase of the problem of the mingle here with those high in authority feeble-minded it is proper that I should in the state and with learned men from first attempt to offer you some idea of far away. But I am in the grip of an my conception of the term. May I not say that it represents a departure from * Spoken at the Dedication of the New Build- j.u n j 4. i i •, j-, , ings at The Caswell Training School, Kinston, ^^^ SO-called mental normal, and that N. c, April n, 1922. the degree of deviation may be so slight 412 SOUTHERN MEDICINE AND SURGERY August, 1922 as to make it difficult of detection, or the departure may be so extreme as to imply the absence of all mentality. In an in- dividual whose physical years are those of manhood or of womanhood but whose mental endowment is that of a child, the condition is feeble-mindedness. Those unfortunate folks who may be grown up physically, but who are unable because of mental weakness to foresee and to deliberate about the consequences to themselves and to others of different kinds of behavior, are mentally below the normal level of inteiiigence. May I go a step further and declare that even though they may understand with some degree of clearness, and yet be unwill- ing or unable to restrain themselves, that they are likewise feeble in mind? Out of these manifestations of inherent mental unsoundness spring much of our modern-day crime and other forms of immorality. Inability to understand the reasons for law and the necessity for self-restraint manifests itself frequently in violations of established customs; in- ability to subject one's self to necessary restraint and self-control is another ex- hibition of mental feebleness. Through the mechanism of the mind all adjust- ments are made possible; continued or frequently repeated social mal-adjust- ment can imply nothing else than disor- der of the mental mechanism. And may I not call you to testify that out of a sound mind spring good morals, and that immorality of every sort whatsoever grows luxuriantly only out of unsound mental soil? About this matter are you troubled by any doubt? Let me say to you that amongst the prisoners in the penitenti- ary in the state of Virginia more than 25 per cent are feeble-minded. In the State Reformatory at Jeffersonville, In- diana, the proportion of feeble-minded was found to be not far from 50 per cent. Dr. Fernoid reported that in the Massachusetts State Reformatory at least 25 per cent of the prisoners were far below the normal level of intelli- gence. In the State Industrial School for Girls at Lancaster, Pennsylvania, almost 30 per cent were found to be mentally sub-normal. But inherent mental in- adequacy is not always found in prison. Of almost 600 young women who lived by walking the streets of Chicago inves- tigation disclosed the fact that half of them had been doomed to seek a living by selling their souls because they were women in their bodies but children in their minds. Fortunately or unfortunately, how- ever, a small percentage of the nation's feeble-minded have come under restraint and control in institutions. It is esti- mated that about three per cent of all school children are mentally sub-normal. What does that mean? For one thing it means that they can never be normally educated ; it means that money and time and effort will be wasted in attempting to drive into them the sort of training designed for normal children; it means the expenditure in the United States of millions and millions of dollars every year in trying to teach these children what they could not learn last year and what they cannot learn next year or the next year or any other year, because of inherent mental incapacity. How many individuals are there in the state of North Carolina who are below standard of intelligence normal for their physical ages? May I say 1,000 without causing you to shudder, or 6,000 without being thought too cruel a judge of mine own people whom I love? Statistics prepared under the supervision of the Surgeon General of the United States Army will tell you that 21 out of every 1,000 of your young men drafted into the army during the late great war were feeble-minded and that about 18 out of the 21 had to be sent back home as unfit for service. What a stupendous and an appalling thing is this matter of mental inadequacy. As a result of rejection from the army of 69,000 men because of mental disorder of various kinds, one third of this number of men were found to be mentally under-developed — and to such a degree as to render them useless as fighting men. In the presence of all this mental un- soundness is it cause for wonder that there is ignorance and immorality, pov- August, 1922 ORIGINAL COMMUNICATIONS 413 r-^y and disease, crime, and sorrow and We are living, we are dwelling, A.retchedness unspeakable? If David In a grand and awful time, knew not that his son Absolom's viola- In an age on ages telling — tion of his own sister was not an erhi- To be living is sublime. bition of mental degeneracy; if the mighty King knew not that the physical r.T>r^Tr^^Tr.,w,r^ . ^r beauty of his son Absolom housed a ^^^^^^TIVE AND PROPHYLACTIC feeble mind which made him disobedient PKACTICE OF ORTHOPAEDIC and rebellious, how shall the prosecuting ^'^ RGERY. attorney and the judge, and the govern- Alonzo Myers. M.D., Chariot lo, X. C. or know the mentally and the morally ^he problems of the orthopaedic sur- sound from the unsound? How long ^^^^^ ^^.^^ ^^^ ^^^^^ ^^^^^ ^.^^^ w. I your great state contmue to prose- j^^^^j^^. ^^^^^ ^^ operative and recon- cute little children? How long will it struction work. contmue to keep them confined m pris- ^^^,.^^^ ^^^ ^^^^^^^ ^^^^ ^^^ ^^^^^^^^ on.^ Hovv long will it send them to the ^^^ necessities of more men to do orth- road with pick and shovel? When will ^p^^^^^ ^^ ^ ^^^^^^ It cease to send thi-ough their taber- ^^^^,^^, ^f the younger men of the nacles ot flesh the deadly current till profession to take intensive orthopaedic their spirits flee away? draining in order that they might be Let me say that I do not believe that equipped to deal with the results of war every one who commits a crime is insane injuries and their sequelae, as well as or weak in mind. But out of an un- those questions of faulty statics which sound mind grows most luxuriantly bad- ^j-e evidenced in soldiers, ness in all its forms. jy^g surgery of war injuries has em- In this institution is begun a mighty phasized the necessity for prophylaxis work. No longer shall we reply upon in regard to future function of parts, the terrible theology of the great apostle and the position for usefulness of va- in explanation of a medical condition, rious members have been pointed out "Hath not the potter power over the over and over again- clay, of the same lump to make one ves- As a consultant orthopaedic surgeon sel into honor and another into dis- to the Fifth District of the Veterans' honor?" Mayhaps these little children Bureau, I am convinced that a large of the good God have come into the number of cases presented for examina- world malformed in order that our tion show faulty statics which play an faith in Him may be made manifest important role in the causation of dis- through service to them. Whence comes ability. Recently I have been conscious this mental unsoundness, this mental of the fact that a large per cent of the inequality that Jefferson knew not when soldiers who present themselves com- he penned the immortal Declaration, plaining of pain in the back, particu- and Lincoln saw not when he spoke at larly the lower back, are of the long Gettysburg? Is the condition born with backed type with varying degrees of the child? Is it an affliction imposed mal-alignment, and in a surprising per during birth ? Is it the result of disease cent, various anatomical deviations in or disaster in innocent childhood? For the sacro-lumbar region are seen by the this State the answer to these questions X-rays We do not yet know the exact should be made by this school. The task relation of these deviations to the symp- calls for mighty forces. But the state tom complex, but the frequency with has aroused from her slumber. She is vvhich we get these findings seems to conscious of her puissance. She is in me to be more than a mere coincidence. the spirit to lend her mind to the solution - of mighty problems. The sun has risen, *R,.a.l WUwo tlio Surgical Srclion, Win- the darkness has gone, the fog has slon-Salcm mecliuK of tlw Nordi Carolina lifted. Medical Society, Aijril 25-26-27, 1922. 414 ORIGINAL COMMUNICATIONS August, 1922 The enormous number of postural die surgeon's office practice, and a cer- cases, both rejected from the service tain per cent in other branches of medi- and still in the service, has been pointed cine and surgery, consists of adults, and out and talked of until it is common in varying degrees, according to the in- knowledge; and the rejected and dis- terest and importance attached to faul- charged for foot defects alone, when the ty statics, the conditions for which these final figures are compiled, will certainly adults are treated are functional faults, be great. When we stop to think what Joint conditions, due to improper the causes of these disabilities are, and weight-bearing, with or without other remember that findings of many inves- definite pathology, arthritis, periarth- tigators show that 70 to 85 per cent of ritis, periostitis, neuritis from such con- cur school children have postural de- ditions as flat feet, pronated ankles, fects, the reaction seems perfectly ob- knock-knee, torsion deformities, short vious. leg, faulty spinal alignment, in one or Under the strain of military life, the both planes, disturbances of alignment potentially weak breakdown, and the and weight-bearing in the pelvic and same holds true in civil life, except that shoulder girdles make up a large part the stress and strain is applied more of our daily work. gradually and the disabilities are not How many cases of subscapular bur- apparent at so early an age. sitis and other shoulder girdle neurites, Although orthopaedic surgery is a from use in malposition, must we see in specialized branch of surgery, it has a the adult before we realize that had very broad outlook and many angles of proper attention been given in the grow- activity. ing years, this end-result would have The surgical corrective aspect deals been avoided ? with pathological and reconstructive How long are we going to teach that problems. Preventive surgery deals not moderate degrees of bowlegs in child- so much with the operative as with the ren will be outgrown, when our offices non-operative type. and clinics are full of adults with valgus Perhaps the more spectacular surgi- ankles and flattened feet because of cal side is alluring to some, but certain- moderate, uncorrected bowleg? ly the influence of preventive surgery The apparent correction of the de- on the health and efficiency of the com- formity by close apposition of the legs ing generation will give as great returns is simply due to the fact that a com- in helping to increase human happiness pensatory angle has occurred below the and usefulness. ankle, caused by the weight being thrust The field for preventive effort is large inward by the curved tibial lever- and many angles might be discussed, In latter years the result of flat feet but I desire to bring to your attention and other disturbances of leg alignment only one phase, namely, physical super- ensues. No amount of ordinary treat- vision in childhood. ment can give these adults anything but As I have just stated, it has been symptomatic relief, shown many times by examiners of The same is true to a lesser extent groups of unselected school children of knock-knees, but more attention is that from 70 per cent to 80 per cent are directed to this in childhood and more physically defective from a postural corrections obtained, standpoint. Torsion deviations: Rarely have we If this is so, and the need for correct- seen much attention given to this condi- ive procedures is so self-evident, the tion, which is quite common and causes question arises— who is to be respon- ultimately nearly as much jomt; and sible for instituting and carrying out muscle strain and tissue changes as de- these corrective procedures? viations in other planes. It is safe to say that in general, at How long are we to treat scoliosis least about 50 per cent of the orthopae- caused by short legs before we attempt August, 1922 SOUTHERN MEDICINE AND SURGERY 415 to institute some general action looking supervisor who is responsible for all the to the discovery early in life of the fac- grammar school vi^ork in the city, tors which underly curvature? It is not too much to demand that a We certainly have all seen and appre- trained director, schooled in preventive ciated the wonderful improvement in methods, and competent to recognize health which is manifested in a body of potential defects and deviations, should soldiers after the routine drill and set- be assigned to each school. It should be ting up work has straightened their her duty to act in an advisory capacity spines and corrected to a large extent to both teachers and parents, to look the general tendency to visceroptosis. over and observe all children who need We know their physical efficiency as special attention to their physical needs, well as their health is improved. Why She could refer these cases to the proper should we not give to all the coming examiners and carry out their recom- generation the value of the lessons in mendations as to any general procedures physical efficiency which our experience decided upon. in the army has given us? Supervision of games is a particular- Reconstruction work is a very neces- ly important phase of this work, and it sary thing in war and the industries, but jg possible by intelligent choice to ar- there should not be much need for it during childhood range certain activities to meet certain needs and to check vicious activities, Constructive work is wanted here, the gy^h as some form of folk dancing, prevention of those conditions which jumping rope, skating, etc., in children most certainly are important factors in ^j^^ flexible flat feet lowering the health and efficiency stand- ^11 physical activities can be altered ard in the adult. Your own children ^o meet the gross needs of the group probably fall in this class, which is 80 ^^^ will thus result in greater value to per cent of the total number of school ^j^g individual TT '• r i. i.- A rough classification can be made How IS a program of constructive , . i ^ • j «•• , . , . . , , ,. , by an examiner properly trained, suffi- physical supervision and education to r ^, , f ,. . , 4. i ^u u u ui. u i- J i_ • • J. cientlv accurate to divide most of those be brought about, and who is going to .^, ' , . j ^ i. i-i j. j , ..„ %,r , ' ■ f with obvious defects like pronated do it .' We have a growing group of ,, r, . n i. ^ ii j J J • u • 1 ankles, flat feet, knock-knees, round men and women engaged in physical , , , j i, n u i , ,. , , , Hi. shoulders, round or hollow backs, un- educational work, only a small percent- , , , . j u i i 4- lu „ , , u r i-- level hips and shoulders, from those age of whom know much of corrective ^ , i methods. As a class they are enthu- "^^^^ "^^^'^^ "°'"'^^- siastic, willing, and interested in this briefly I would suggest a method as problem, but they lack guidance. follows: At the beginning of the quar- Only in our large centers do they ter of semester, the new pupils are Im- come in contact with orthopaedic pro- ed up and the examiner, accompanied by cedures and even there only the high a secretary, passes down the ine and schools and colleges have gymnasia, so notes, first, all cases of unlevel shoulders that there is practically very little at- —again, passing a hand down the curve tention given to the postural defects in of the waist and hips and then placmg the grammar grades. This is expressly the thumbs on the anterior superior the age when the most careful work spine of the ilia, unlevel hips or tilted should be done- Pelvis are noted. The most effective and far-reaching The secretary notes the pupil's name, work must be done during the grammar each time under each defect. Lining' school age. As gymnasia in grammar them up again, the examiner approaches schools are seldom seen, all the exer- from the end of the line, passing the cise the children have, which could have hand over the back, notes prominence of any corrective value whatever, is given scapulae, round, flat or hollow back, and by the grade teachers under a general head position. 416 ORIGINAL COMMUNICATIONS August, 1922 Postion of the squad is again assum- The worst cases could be taken out ed and by slight pressure beckward on in squads and have special exercises giv- the knee as well as by direct inspection, en, but as it will take some time to get back knees are detected. Next, have to this stage, a good start can be made the pupils stand with feet parallel, by modifying as much as consistently knees touching- Those whose malleoli possible all the games and activities touch and condyles do not, obviously which will influence these conditions, have varying degrees of bowlegs and Supervision should also be extended the converse detects knock-knees. to physical surroundings, seats, desks. In the feet parallel position, if the chairs, etc., and their adjustments ex- patella points toward the median line amined to see that they are correct for of the body and not forward in the me- the various children under considera- dian line of the leg, there exists inward tion. rotation of the leg and compensatorily In acting in an advisory capacity to pronated ankles or relaxed arches. the parents, much good would ensue- Bring the class to attention again Inquiry should be made in regard to the without calling attention to their feet child's habits and activities while out and note foot positions. In gymnasium of school, home surroundings, bed pos- slippers it is easy to observe faults in tures, feeding, hours of play and sleep, foot alignment and notation is made as Clothing and its effect on posture to pronation and relaxed feet. should receive its share of considera- When this data is assembled it will tion, and most mothers are very glad to be found that certain ones will be regis- be informed as to correct corsets and tared for two or three defects, or, in a correct waists, brassieres, etc. word, are generally relaxed This worst Whenever it is possible to have gym- group should have immediate attention, nasium facilities, the supervisor of cor- Word should be sent to the parents for rective activities should change type, or- permission to make a detailed examina- der, and progression of exercises to ob- tion with clothing removed, and in cases tain the greatest individual benefits to that need expert attention they can be the whole group taking work under referred to the proper clinic or ortho- her. I jj f^j paedic surgeon for necessary care. One example of this would be shown. In this way there will not be a loss of for instance, by a method which is used a month or more before the examiners in some gymnasiums and which has been are aware of some of the worst cases, subsequently used in several schools, and, furthermore, they would not be namely to plan out a whole progression able otherwise to estimate the size of of exercises given in recumbent, pro- the groups needing special attention to cumbent or sitting positions. Enough certain things. stools and mats should be included in On this basis they can adjust their the gymnasium equipment to make this corrective and general gymnastic pro- possible, cedures. You probably know the value of ton- r^.n. ' . , ., u 4-u ,„ ing up exercises in these positions and Fifty or sixty pupils can be thus ^ ^, . ,- t ^^ 1 , . "^ , J -o-u use them in your own practice as i do, roughly gone over m an hour and with , ""^ "['^ ^, , ^ „ . 1-, ,/ - , 1 1 . -^ but they can be used as well m group a little experience and knowledge of ""^Z" -^ .^, . ,. ., , , XI, u ^ 4- 4-^A work as with individual cases, types the gross errors can be detected. In any group of school children fully Some of the advantages of the meth- 65 per cent will have two or more of the od are, briefly: The lying position above mentioned deviations; consequent- rules out the effect of lateral asymme- ly, the earlier they can be recognized, tries, such as short leg, unilateral flat- and the earlier any or all of the proper foot, or knock-knee with its pelvic tilt, prophylactic procedur'as can be insti- ^^^ scoliosis. tuted, the better for the children thus The straightening out of all spinal afflicted. curves in the early stages. August, 1922 SOUrilKKN .M KDICINK AND SUKCiEIJY 417 The fixation of the scapulae and cor- lize that the well trained physical direc- rective effect on antero-posterior curves, tors, who are graduated from schools The margin of safety allowed in ref- giving courses in corrective orthopaedic erence to heart and rspiratory strain, therapy, are to be the ones to transform The improved position of the viscera, our desires into facts, in dealing with The sitting posture is an especially this phase of the preventive and pro- good one in fatening the lumbar curve phylactic problems of childhood, while the shoulder, scapular, and chest The founder of orthopaedic surgery exercises are given. included the postural and potential de- Fatigue is not developed so rapidly viations in childhood within the purview because of the lessened balance strain- of this branch, and it seems as though In short, it allows corrective work to the responsibility for training these per- be given in corrective positions, a state- sons rests with the orthopaedic sur- ment which should be axiomatic. geons. Instead of having the high majority If, then, we all will assume our share with postural defects stand and exer- in the education and training of physi- cise in position of faulty alignment, is cal directors, we should wse our in- it not betetr to have the small majority fluence to broaden the scope and raise who are normal assume the positions the c-ignity of physical training as a and do the work which will gain the scientific branch of education, maximum good results for the needy majority? I recognize the fact that in two or three of the larger centers where there EARLY DIAGNOSIS OF BREAST are many orthopaedic surgeons, some TUMORS * of them have long been giving time ani thought to the development of physical ^y .las. W. Gibbon. M.D.. Charlotte, N. c. trainers and gymnasts, but through the Fortunately, today one sees very little country at large how many state normal ^^^^ ^^ th^ classical text-book picture schools, colleges, and universities giving ^^ carcinoma of the breast, namely, a major courses in physical training, have 1^^.^^ ^^^^ ^^ the breast, attached ante- orthopaedic surgeons on their faculties ^.j^^j^. ^^ the skin over a wide area, pos- or even remotely connected with them? teriorlv fixed firmly to the muscles and It IS perfectly obvious that there are ^^^^^ ^;.^11^ retraction of the nipple, and not enough men interested in this line gj,^^^^, enlarged glands in the axilla and of work to see even a fraction of this ^bove^he clavicle. Everywhere it may 80 per cent of children who need the at- y^^ ^^^^^ ^-^^^ cases of breast cancer are tention of trained individuals. Conse- presenting themselves for treatment quently, if this field is to be cultivated ^^^^ ^^^^^^ g^^h extensive involvement and a harvest gained, it will have to be ^^^ occurred. This is probably due to done largely by men and women trained ^^^ persistent propaganda carried on by to do it- tj^g American Society for the Control of All of us who are or have been con- dancer during the past few years,, cul- nected with the reconstruction work minating in cancer week so recently appreciate that a great part of the y^^^^ jt is also probably due to a credit for the results obtained belong to changed attitude of physicians towards our Reconstruction Aides, the greater ^n breast tumors. It is now common number of whom are physical directors, knowledge that every tumor of the We are keenly conscious of the differ- breast is a potential cancer, and that ence in value to this work of those rnany cancers originate in benign tu- who are experienced directors and those mors, and no longer in the case of an who hp.d simply some special and inten- «ivp froln.-nfr * Read before the Winston-Salem Meeting of Sive traming. ^^^^ ^.^^.^j^ Carolina Society. April 25-26-27, This fact alone should make us rea- 1922. 418 ORICINAL COMMUNICATIONS August, 1922 undiagnosed tumor does one pursue the need is a careful and more accurate plan policy of "waiting to see what develops." of diagnosis. Benign lesions must be This increased enlightenment of the recognized if the patient is to be spared laity regarding the character and man- the ruthless mutilation and greater haz- ner of cancerous growths, and a lessened ard of a radical operation for cancer, hesitation on the part of the physician when only the simple operation is re- in advising treatment or consultation in quired. On the other hand, the cases of all cases has together tended to bring early carcinoma must be diagnosed, lest forward cases of cancer in incipiency, the golden opportunity for cure is to be and very early stages of development, lost. Clinically the benign and early much before the clinical signs of actual malignant tumors are quite similar, and cancer can be demonstrated. In other the diagnosis by this method is not pos- words, we are seeing a steadily increas- sible. These conditions may then be ing number of "doubtful breast tumors," considered under the one caption, "clin- among which a considerable percentage ically doubtful breast tumors," and it is will be benign, and the others, early and in the diagnosis of these that there is locally malignant. The first, require greatest concern. After a review of the never any more than simply enucleation recent literature, and experience in the of the tumor, or excision, with a sur- laboratory of surgical pathology, as well rounding zone of breast tissue for a as the general practice of surgery, it cure. The second, the early, locally ma- seems to me that a really accurate diag- I'gnant tumor without even the clinical nosis may be best reached after an asso- signs of malignancy is the type of case ciated study of the clinical features, in which immediate operation will prom- macroscopic and microscopic characters ise the greatest possibility for a com- of the tumor. It is therefore with the plete cure of the cancer. Many large correlation of the findings from these clinics are reporting greater and greater that I offer as a plan of dianosis. number of cures following operation for Clinical symptoms, signs and age : cancer in these very early cases. We Bloodgood in 885 cases of breast tumors are encouraging this as the ideal method has noted only one case of positive can- of attacking the destructive invasion of cer in a woman below the age of twenty- carcinoma of the breast, we are educat- five. This patient was 21 and the tumor ing the public through various organiza- had been present but a few months. In tions to a knowledge of the fact that a patient under 25 years, with a breast "cancer is not a hopeless disease, and tumor, the chances of a malignant tumor that the earlier it is operated upon, the are remote. After 25, age does not aid better the prognosis," and in so doing, any for cancer has been observed from we are multiplying the problems of diag- 26 to 70 years and over, as well as all nosis, and assuming a greater responsi- types of benign tumors. Nor does ad- bility. vanced age necessarily indicate that the It is a fact also that we are seeing tumor is cancer. Quite recently we re- more cases of benign tumors of the moved a fibro-cyst-adenoma. a perfectly breast than ever before, and because of benign tumor, from the breast of a the instruction of the laity regarding woman 60 years of age, which had been these lesions, and their significance. For- present for twenty years. During child- merly the percentage of carcinoma of hood tumors of the breast are unusual the breast was given as SO';* to 90% of and benign, and need not be removed all breast tumors. This is not true in unless they grow or give great pain. At the more recent statistics. Bloodgood puberty benign conditions of the breast gives the recent rise in percentage of are often first observed. The attitude benign breast tumors from 32'^( to 59*;; . toward all lesions at this period should Others give SOS' to 35^y as frequence of be conservative. Intense pain, a rapidly benign lesions. growing tumor, huge enlargements of It must now be obvious that the great one or both breasts are the only indica- August, 1922 SOU'lHERN iMKDlLl.NK AND SURGERY 419 tions for operative interference. never an indication for operation. Duration of the tumor is not as a rule Discharge of blood from the nipple of any great value. It might have been has for a long time been taken to mean present a long time and only recently cancer. That this is not justified has observed by the patient. Also a benign been shown by many observers. This tumor may have been present for years symptom therefore alone or with an as- and only very recently become malig- sociated tumor is not an indication for nant. What is perhaps of more value is the radical operation. When associated the rate of growth. A rapidly growing with a tumor, the tumor has been more or even slowly progressing tumor sug- frequently a benign lesion, and the most gests carcinoma. The surgeon therefore common benign lesion causing discharge may be aided to some extent by a history of blood from the nipple is the intra- of long duration without any change in cystic papilloma. the size of the tumor. But this is only Retraction of the nipple is notoriously arbitrary, and no rule can be fixed. Cases a sign of cancer, and at times may be of cancer have been reported with a his- the first thing noted. It is so exceed- tory of tumor in the breast as many as jngly rare in benign conditions that it thirty years. (Bloodgood.) may be looked upon as almost a positive Multiple Tumors in One Breast : — In sign of malignancy. This is particularly a majority of women with cancer of the true when there is no history of a pre- breast, there is a single tumor. Cancer vious mastitis, or abscess, and the re- at the outset is commonly a single lesion, traction is not congenital. Retraction Multiple tumors in one breast argues of the nipple may indicate cancer when against malignancy. On the other hand, no positive tumor can be palpated in the benign tumors are sometimes multiple breast. from the beginning. The most common Dimpling and sl'ght fixation of the multple tumors are the simple cysts and skin are important signs of cancer, the intra-canalicula myxoma (Blood- These may be so slight that they will es- good) and these of all benign tumors cape observation unless specifically have the least tendency to become ma- looked for. When present with or with- lignant. I have records of two cases of out a definite tumor, either one or the multiple tumors and each a fibro-ade- other are very suggestive of cancer, neno-myxoma. Multiplicity, then while Dimpling of the skin was the first symp- never a positive sign of benignity, when lom to be noticed in one of our cases of found with other strongly benign, char- scirrhus carcinoma, acteristics may serve as confirmatory Glandular Enlargement.— The pres- evidence. erice or absence of enlarged glands do The discovery of a lump is most com- not merit the diagnostic significance monly the first symptom to be noted, that is usually attached to them. In More rarely discharge of blood from the certain benign lesions of the breast the nipple, retraction of the nipple, dimpling glands may be palpably enlarged. While of the skin, and glandular enlargements in cancer there may be metastases to the in the axilla are first observed. glands of the axilla and yet no palpable Pain is said to be more frequently enlargement. I have seen in cases of present in benign lesions than in malig- well developed cancer glands in the axil- nant, and in all cases more or less un- lary fat which even after dissection and usual. Pain is not a sign of cancer, nor removal show no gross change, and yet does it necessarily signify any grave under the microscope show extensive in- lesion of the breast. Pain in one or both filtration with cancer cells. In a small breasts precedes the menstrual period in number of cases of cancer of the breast some women, and at the cessation of the the patient's attention has been called flow stops, A feeling of tingling in the to the disease by nodules in the axilla, breasts may be an early suggestion of r-nd the tumor in the breast was not pregnancy. Pain without a tumor is felt until later. The involvement of the 420 ORIGINAL COMMUNICATIONS August, 1922 supra-clavicular glands is a late occur- section may be removed, frozen and ex- rence. amined immediately under the micro- The presence of a tumor in the breast scope. The diagnosis then in nearly all is usually the first and most important cases is revealed and the indicated treat- sign or symptom, and should be enough ment continued. Davis remarks that the to warn the patient to seek medical ad- "ideal operation for breast cancer is the vice. Benign tumors are generally free- one that begins as an exploratory inci- ly moveable in all directions, are not at- sion." Bloodgood states that "no w^oman tached to the skin, or chest v^all, cause should be subjected to an operation for no dimpling of the skin, and no retrac- a breast lesion, except for a lactation tion of the nipple. In a case clinically mastitis abscess, unless the surgeon is cancer, there is no such freedom of prepared to make the diagnosis at the movement, and one or more of these fea- exploratory incision and to perform the tures may be present. The easily recog- complete operation for cancer if indi- nized cases of cancer are the late cases cated." If the lesion is cancer, the in which the prognosis is poorest. The wound is carbolized and treated with al- type of cancer that we must be able to cohol to seal up the opened mouths of the detect is the early, freely moveable one. lymphatics, the instruments and gloves if the best results are to be attained are changed, and the radical operation from the treatment. performed. If the tumor is not cancer. In other words, when the malignant either enucleation of this is done, or the tumor, so early as to simulate the benigh tumor and a surrounding zone of breast In other words, when the malignant tu- tissue is excised. This method is supe- mor, so early as to simulate the benign rior to the older plan of excising a por- lesion, can he recognized and radical tion of the tumor for microscopic diag- treatment instituted, there is the great- nosis and waiting two or three days be- est prospect of a complete and perma- fore operation. There is less liability of nent cure. It is in the diagnosis then stimulating lymphatic transference of of these "clinically doubtful tumors," cancer cells, when after the exploratory that I wish chiefly to call your atten- incision, immediate treatment is begun, tion. No one would wait in order for Exploratory Incision.— Holding the the tumor to develop sufficient charac- tumor firmly between the fingers of the teristics to make a diagnosis ; it is also left hand, and drawing the skin tight a serious thing to do a radical amputa- over it, an incision is made directly over tion on every doubtful tumor of the the tumor, radiating from the nipple, breast, when probably a considerable Hemorrhage is carefully controlled as it number are benign and curable by a obscures the picture, and the incision simple excision of the tumor, and still we carried directly down to the tumor. As should not like to lose the great oppor- the tumor is approached the behavior of tunity of abolishing the disease by per- the areola and breast tissue is critically forming an incomplete operation when observed. When the condition is benign in reality the tumor is cancer. The clin- the surrounding areola and breast tissue ical signs and symptoms have failed, have a tendency to retract under the ten- and there is nothing left except the path- sion, and the tumor seems to pop into ology of the tumor to solve the ques- view. There is no adherence of the sur- tion, and settle the plan of treatment. It rounding tissue to the tumor, there is a is exactly this that I wish to emphasize, capsule, and it is usually possible to com- The pathology of the tumor only in these pletely separate, or enucleate the tumor circumstances can disclose the true na- from the adjacent tissue. The borders ture of the lesion. Exploratory incision and outlines of the tumor are clear and in these doubtful lesions must be em- distinct from the rest of the breast tis- ployed. The surgeon then may inspect sue, and there is no difficulty in deter- and examine the gross features of the mining where the one ends and the other tumor and if still there is any doubt a starts. These features are in marked August, 1922 ORIGINAL COMMUNICATIONS contrast to those observed in cancer. In cancer there is no capsule, the tissue ad- 421 and pentrating outward into the sur- rounding- structures, and no line of strict demarkation can be found between the tumor and the other breast tissue. If References. Enrly Recosnition of Breast Cancer. Welch. ^ , , ^ Xeb-.aska M. J. 3; 153, May, 1918. jacent IS firmly adherent and cannot pOS- clinical Efficiency and Terminology. Mc- Sibly be separated, and as a result there Cartv and Conner. Surg., Gyne. & Obst. 29; is not the retraction of the tissue wit- 44, July. 19. nessed in the benign lesions. Strands Associated S-udy of the ClinV-^l. Macroscopic „ , , , J. i;^„ and Microsconic Appearancei of Carcinomatous, from the tumor may be seen radiating ^^^^^^^ ^^ -^^^ ^^^^^^ Rutherford-Darling. M. J Australia. 2; 217. Sept. 14, 1918. Precancerous Conditions of the Breast. Welch. Nebraska M. J. 3: 81, March, 1918. Assccated Study of the Clinical, Macrocsopic, . , and Microscopic Appearances of Carcinomatous necessary the incision may be carried Tumors of the Breast. Rutherford-Darling. M. J Australia. 2; 240, Sept. 21, 1918. Dfferential Diagnosis Between Benign and Malignnt Tumors of the Breast. Summers. Nebraska M. J 3; 297, October, 1918. EttIv Diagnosis of Breast Tumors. Waters. Nebraska :\I. J. 2: 490, Nov., 1917. Cl'nical Diagnosis of Tumors of the Breast. Here the surface Emmen. Nebraska M. J. 6: 75, March, 1921. Career of the Breast. Nicholson. British M, J 8: 527, April, 1921. A Plea for Woll-Directed Treatment, Based on More Accuvnte Diagnosis of Breast Tumors. Painbrd'^e Wisconsin M. J. 19; 619, May, 1921. Eariv Dagnosi> of Breast Tumors. Grant. Ca^id ATed Mon*hlv 5: 446, Nov., 1920. Ai Aralvsis of 102 Cases of Tumors of the P'-'^ast. Winslow. Ann. Surg 74; 341, Sept, 192'. riinicnlly Doubtful Breast Tumors: Their n=n«rr,(,«j<^ and Treatment. Bartlett. Ann. Surg :?,: 740. June, 1921. CM-roma of the Breast. Oliver. Ann. Surg 65: 66. 1917. Earlier Diagnosis of Cancer of the Breast Hilton Nebraska M. J. 6; 9, Sept., 1921. F-^d-Results in Cancer of the Breast. Green ough and Simmons. Boston Med. and Surg. J. : 185. Sept. 1, 1921. Cancer of the Breast with the Study of Re suits Obtained in 218 Cases. Sistrunk. Penn Med. Jour. 4; 24, Aug., 1921. Cancer of the Breast. Davis. Archives of Surg. 2: 3. Sept., 1921. on through the tumor and all of these features multiplied, and any degree of infiltration can be noted. The cut sur- face in the benign tumor is rubbery and has a tendency to bulge beyond the cut edge of the capsule. This is not true in the malignant tumor is granular, .sometimes quite degenerat- ed, and some of the tumor substance can eas'ly be scraped away. If the tumor is cystic, the cyst is laid open, and the interior surface of the walls examined carefully. This is im- portant because certain types of carci- noma develop from papilloma growing into the cyst cavity from the cyst wall. If the contents of the cyst are bloody, many surgeons consider it an indication of malignancy. If the contents are clear, and there are no papillary outgrowths, and the cyst presents a bluish color it is considered benign. A papillary cyst- adenoma should be inspected very mi- nutely for signs of infiltration and carci- nomatous changes, as it very readily de- velops into carcinoma, and really most frequently it is treated as a definite pre- cancerous lesion, and the breast ampu- tated. When the diagnosis cannot be made from a study of the gross tumor at the operating table, a section is removed, frozen and immediately examined by a pathologist. In the majority of cases though, the surgeon familiar with the This symptom is of perennial interest, gross pathology of breast tumors can for every physician encounters it under make the diagnosis, and proceed with some pathologic condition and from va- the operation as indicated by this. In a rious causes. To locate the underlying smaller number of cases, the microscop- origin, thereby placing its therapy in ical diagnosis is necessary, and it is only the proper category, is sometimes difl^i- the very rare tumor which cannot be rec- cult in tho extreme, taxing to theutter- ognized fully by the assoc'afon of these most both scientific knowledge and dias'- methods. nostic acumen. VOMITING. George M. Niles, Ph.G. Atlanta, Ga. M.D. 422 ROUTTIEUN MEDTCINE AND SURGERY August, 1922 It is believed, therefore, that a discus- merycism is occasionally met with, in s'on of this subject will be of interest, which some of the stomach contents may and, while most of this study is from the be regurgitated into the mouth and observation and experience of the swallowed again. In this connection it writer, some of it is necessarily collated ; might be said that merycism, while com- for no single individual, no matter how monplace and apparently comforting in extended his opportunities, can have had a cow, is freakish in a human being, every phase of this disturbing phenom- Ejection of unswallowed food may enon under his professional eye. also be noted in conditions, where the In its narrow sense, vomiting implies mechanism of deglutition is upset, as in the ejection through the mouth of part bulbar paralysis or diptheritic paralysis, or all of the stomach contents. This, The regurgitation of milk in normal however, may be simulated closely by breast- or bottle-fed infants is simply ejected matter, which has never an "overflow," and is not true vomiting, reached the stomach. In certain eso- jn the mechanism of vomiting the phageal abnormalities, food may be parts concerned are the muscular coats swallowed, and, after a time, be returned of the stomach, the sphincter at the ear- in a manner resembling true vomiting, diac orifice, the diaphragm, the abdom- In malignant disease of the esophagus, inal muscles and the vomiting center in in fibrous stricture, cardiospasm, pres- the medulla. Conveying the vomiting sure from without the esophagus, as by impulse are the efferent nerve fibers in an aneurysm or some neoplasm, in idio- the vagus supplying the musculature of pathic dilatation of the esophagus, or in the stomach, the phrenics to the dia- the presence of diverticuli, food may be phragm, and the spinal nerves supply- returned through the mouth, either ing the abdominal muscles. In the act promptly or after many hours. If the of vomiting the walls of the stomach obstruction has been of long standing or contract, the diaphragm is pushed vio- near the cardiac opening of the stom- lently downward, while forcible con- ach, the ejection of the food may be de- traction of the abdominal muscles oc- layed considerably. curs. The cardiac sphincter is usually A diverticulum, especially in the up- relaxed and the pyloric sphincter closed ; per part of the esophagus, may produce but if the latter is relaxed, bile and in- no distress, until is gradually fills up. testinal contents may be in the vomitus. Then either pressure-pain or dysphagia In retching, the same muscular phe- will ensue until the pouch is emptied, nomena takes place, but the sphincter Sometimes, also, there is an incomplete does not relax. In pyrosis, or "water- obstruction at the cardia, whereby a brash," relaxation of the cardiac sphinc- part of the ingested food reaches the ter occurs, but there is absence of the stomach, but with such difficulty that violent muscular eflforts. the esophagus becomes enormously di- The fundamental causes of vomiting lated above. The writer has seen two naturally fall into two divisions— those cases, in which the esophagus was fully acting directly on the vomiting center as large as an ordinary stomach, and in and those acting reflexly. The latter is each instance the attending physician the larger one, including most of the thought that vomiting was present, pathological states of the stomach, some Such conditions are easily diagnosed by visceral diseases and disturbances of the roentgen ray; and, in addition, the special senses returned matter is undigested is not The following are the principal cen- acid, may contam mucus or blood, or tral causes: Drugs, as apomorphine or even portions of growth in cases of car- anesthetics, uremia, diabetes, acute yel- wTn'.lA ^""^''-''iT.'^^r ^'/P^"^' 1«^ atrophy of the liver, Addison's dis- caution "^^"^P^'^t^d ^^th extreme ease, onset of acute infections, especially . ■ . in children, pregnancy, and cyclic vom- A condition called rumination or iting. August, 1922 ORIGINAL COMMUNICATIONS 423 This symptom in pregnancy may be by its sudden onset when the individual partly reflex and partly toxic. Exam- is subjected to offensive smells or tastes, ination of the urine will disclose renal to repulsive sights, or even the recital of pathology in uremia, and the onset of some particularly revolting circum- drowsiness and coma in diabetes may be stance. accompanied by vomiting. Persistent Vomiting, originating from pathology vomiting, where jaundice is in evidence, of the central nervous system, brings to should lead to the suspicion of acute yel- mind its frequencv after concussion of low atrophy. When associated with ex- the brain, cerebral tumor or abscess, treme weakness, pigmentation of the meningitis, hydrocephalus, cerebral skin and low blood-pressure, Addison's hemorrhage, or thrombosis of cerebral disease may be suspected. Cyclic vomit- sinuses. The gastric crises of tabes ing of the young may generally be re- dorsalis are a classical illustration of garded as an expression of acidosis. The vomiting arising from disease of the vomiting, which so often ushers in the spinal cord. specific fevers in children, may be con- Occasionally vomiting has been traced sidered due to the action of a specific ^^ middle-ear trouble. Migraine pos- toxin on the cerebral center. g^^^^g -^ ^^ ^ frequent and distressing In considermg vomiting due to reflex concomitant, while it is occasionally causes, we first mention those in which ^^^^^^ jj^ epilepsy. The vomiting of sea- the stomach is directly involved, as— sickness is familiar to all. What is called irritating articles of food, emetics, pois- functional or hysteric vomiting some- ons, the presence of acute, chronic, or ^jj^gg means that the puzzled practi- phlegmatic ga.stritis, dilatation and ^ioner is "up a tree," and has to fall back hour-glass contraction of the stomach, q^ ^his somewhat vague and nebulous pyloric obstruction due to malignancy, diagnosis for the want of more exact in- stricture, hypertrophic stenosis (in in- formation. ^^.';^'^'«^»r''"''^''"^^^^^'^°''''^''''"' Certain' general lines may be laid without. Then vomitmg may arise from ^^^^.^ ^^ ^^ ^^,^^^ importance in the ac- venous congestion, as in portal obstruc- ^^^.^^^ diagnosis of the cause of vomit- tion or cirrhosis of the liver. Vomiting ing. There should be considered its re- IS also a rather common symptom in gas- j^^j^,^ ^^ ^^^^^ -^ ^^^^ ^^^ ^^ ^^^^ i^^^r- tric ulcer or malignant erosion of any ^^j ^^^^^^ ^ ^^^1 -^ ^^^^^^. ^^^^^^^ part of the gastric mucosa. ^^^^^ ^^ ^^^ ^^ p^j^. ^^^^^^^^ ^^ ^^^ Proceeding down the intestinal canal, attended by definite nausea. The ab- we may find vomiting brought about by gence of nausea is of significance, for intestinal obstruction, appendicitis, in- nausea is usually present in vomiting testinal worms, following enemas, peri- due to trouble in the alimentary tract tonitis, biliary colic, renal colic, Dietl's ^nd visceral organs, while it is not infre- crisis, acute pancreatitis. Among general quently absent in diseases of the brain, causes may be mentioned the vomiting j,, tion of the vomited matter often in pulmonary tuberculosis, due to irrita- ^^^^^g j^^j ^^1 information. Alcohol tion of the bronchi or fauces, or the ^^^, ^^^,^^.^ -^^^^^ 3^^^ as carbolic vomiting so often observed in pertussis. .^ ^^^ -^ ^^j^j i^^ ^^^ ^ ^^arac- This symptom may also fo low a blow ^^^-^^.^ ^^ ^.^ile a decided fecal odor on the epigastrium or testicle, or even a generally tells its story. Blood may be kick upon the internal semi-lunar carti- ;resent, either dark or bright red, or of Z,-rI .' "''• ' '7^^ ?TZ'' ^ coffee-ground appearance. Slight vom ting of pregnancy needs only to be gt^g^kg following severe vomiting or ZTlZ ' f Tl T ^"^^ology retching are generally due to the rupture sometimes ascribe it to retroversion of ^f ^^J^ ^lood vessels in the esophagus tne uterus or ovarian disease , j j 4. n j ocdoc. ^^ pharynx, and do not usually deserve That vomiting may be precipitated by the alarm in the patient's mind that its insults to the esthetic senses, is proved sight elicits. In pertussis, blood is often 424 SOUTHERN MEDICINE AND SURGERY August, 1922 mixed with mucus from the respiratory tinguish and to distinguish means to passages, and the contents of the stom- know by visible marks, ach are violently ejected during the par- To the young graduate, who goes out oxysms. The condition of the vomited to work with the text-book ear-marks food is also worthy of attention, for the of disease fresh in mind, the way to his presence of substances, as raisins or diagnosis seems plain enough. But is seeds, taken perhaps many hours or days it a commonly occuring fact that "dis- previously, would mean motor insuffi- tinctive marks and characteristics" of c'ency of the stomach, either with or disease loom up to glare the way to a without pyloric obstruction. Shreds of diagnosis ? Let the observation and ex- meat vomited in an unaltered condition perience of the care-worn physician an- some hours after being ingested, indi- swer. cate deficient protein digestion. As a matter of convenience, diagnosis The reaction is worth noting, for fol- may be considered under three heads: lowing corrosive poisoning this may be 1. Mediate diagnosis, strongly acid or alkaline according to the 2. Intuitive diagnosis, nature of the poison. If there is a 3. Non-diagnosis- medico-legal feature involved, the vom- Mediate diagnosis is in harmony with itus should be preserved for analysis, reason. Mediate diagnosis, therefore, Quite often microscopical examination by indubitable cerfainty, does not ad- of vomited matter may show sarcinae, mit of any reasonable cause of doubt- yeast cells, the Boss-Oppler bacilli, or ing. characteristic cell elements from a ma- Intuitive diagnosis is in harmony with lignant growth. Intestinal contents are instinct. sometimes mixed, and bile is a rather Intuitive diagnosis is knowing by di- common content after severe or pro- rect cognition, with utility for a result tracted vomiting. and is, therefore, justified. The foregoing will in the main cover Non-diagnosis involves a contradic- the causes of vomiting, and happy may tion. It is the result of human weak- be the troubled physician, who can al- ness and may be ascribed to one of two ways decide accurately just how to dif- causes: feretniate and classify this distressing i. Ignorance, symptom; for in the vast majority of 2. Carelessness. instances a proper understanding as to Ignorance is latent knowledge unde- the underlying or direct etiology, will veloped, for what is unknown today may not only govern the therapy but will be known tomorrow. Ignorance, there- largely aid in a correct prognosis. fore, is the undeveloped mine of knowl- edge. In the absence of this truth, there could be no progress — today and A WORD ABOUT DIAGNOSIS, WITH tomorrow would remain as yesterday. ILLUSTRATIVE CASES, ESPE- Carelessness is unfolded knowledge CIAL THE REPORT OF A CASE not comprehended- If comprehended, OF METASTATIC ABSCESS FROM J^ere could be no non-diagnosis, for knowledere made manifest evolves into INTESTINAL INTOXICATION. diacmosis By Dr. Stephen Harnsberger, Catlett, Va. Ignorance is finite and at times ex- Diagnosis, Webster tells us, is the de- cusable. Carelessness is optional and termination of a disease by means of always unpardonable, distinctive marks or characteristics. The A mediate or intuitive diagnosis is original meaning of the word is to dis- always better for the longevity of the patient, while a mediate or intuitive Written for the meeting of (he Tri-Stafe prognosis unquestionably redounds best Medical Association, Norfolk, Va., Feb. 22- to the welfare of the physician. And 23, 1922. while this is commonly true in regard to August, 1922 ORIGINAL COMMUNICATIONS 426 both diagnosis and prognosis in general diagnosis based on the preponderating no one can deny the fact that we, as proportion of our cures, unless it be that physicians, should never, not even in inner consciousness of the truth that the seemingly most trivial case, treat even in the majority of our cases, we lightly or carelessly the factor of diag- are just a bit doubtful in our own nosis. According to Osier, I believe it minds, of the correctness of both our is, we cannot make more than 40 per diagnosis and prognosis, believing as cent of mediate diagnoses ; then allow- every experienced and honest physician ing 10 per cent of intuitive diagnoses, does, that perhaps nine cases in ten we readily see what a fearful stretch of would get well without our professional darkness we have to grope through in direction and guidance and perhaps also caring for the other half of our cases, that some others now dead might be The very fact that 50 per cent of our living. work is done in blindness, is much the We hear a great deal and we read a more reason why we should strive as- great deal about the importance of a siduously, persistently and intelligently correct diagnosis, and we see the pub- to discern the hidden conditions of the lisher's announcement of volume after diseased human body— by body I mean volume on the subject of diagnosis and the unity of moral, mental, physical, yet, if we come down to every-day facts including family history, habit and the and exclude the many cases that would influence of environment. have gotten well without our interven- Not long since I heard a well known tion, we see that the actual number of local surgeon say that a certain distin- cases requiring diagnostic acumen is guished author and clinician of Phila- very few. Hence, it has occurred to me delphia was the finest diagnostician he that the very fact of the happy ending had ever known. And what do you of this great preponderance of less im- think he gave as a reason for the opin- portant cases tends to and does render ion he expressed? This — that he had us careless and inattentive, so that seen the doctor come to his lecture hall, when we are brought to face a really announce his diagnosis and treatment, puzzling case, our diagnostic acumen is and that almost invariably the sequence not found well edged and for want of — a cured patient — proved the correct- this constant training we cannot see as ness of his diagnosis. far into the millstone as we should do. Now, it seems to me, if this be the This it seems to me is one reason, at criterion of one's success as a diag- least, why the few succeed and the nostician, that very few of us need many fail as diagnosticians- The many worry or grow old over our shortcom- by inattention to the little cases fail to ings in this one particular at least, for grasp the conditions presented by the with any of us, in what proportion does few— or unusual cases. A hit and miss the number of our deaths compare with method of diagnosis does not educate the number of our apparent cures? Is the physician and it is oftentimes disas- the paucity of our number of deaths to trous to the patient, the multiplicity of our number of cures The experience resulting from a close the way to judge as to the character of observation of every case, will on many our diagnostic acumen? And if this is an occasion lead to a correct diagnosis, not the way, in what other way can even without the confirmatory evidence one arrive at a correct judgment in the of plain objective symptoms and signs, matter? It is not the only way, for The judgment trained by close observa- post-mortems also reveal the correct- tion and long experience learns to cor- ness, as well as the faultiness, of our rectly interpret the collective clinical diagnosis. But as corroborative reve- findings and a correct diagnosis is often lations or post-mortems are rare, com- made in advance of the condition itself, paratively speaking, there should be How and wherefore the diagnosis is nothing to make us dissatisfied with our made is not always explicable even by 426 SOUTHERN MEDICINE AND SURGERY August, 1922 the one who makes it. It is simply this that the mental affinitives of the diag- nostician are satisfied and all else is shoved aside as of no present import, ance. It is true that we may study each case and we may be deceived but in the deception there is this consolation — it has made us more intelligent and so put us more in harmony with reason. The basis of success in diagnosis is found in instinct and experience, with a thorough understanding of the the- oretical ground-work as a necessary concomitant condition Carelessness in clinical observation lessens experience, which in turn tends to inhibit the faculty of diagnosis and naturally the value of diagnosis de- creases as carelessness in clinical obser- vation increases. Therefore, gentlemen, and especially the younger men in the profession, do not scan over any case if you would know the hidden cause, for you will find later on in your profes- sional career that the hidden case is, as a rule, only a bigger evolution of the slight, and, as you thought, innocent lit- tle case. The stitch in time saves nine in medicine as well as stockings, but you cannot know where and when and how to put that sitch unless you first recognize the rent that needs it. Imbued with the importance of the first slight deviation from the normal and its cause, you can the more readily trace the next step in the beginning degeneration and so on to its ultimate pathological effect, so that when you meet with the unusual case you are in the best possible position for retrospec- tive reasoning and from the tangible facts thus elicited, you have at least a reasonable tenable basis for a rational diagnosis. No man, however intelligent, can skillfully and properly repair a compli- cated machine unless he knows every piece and part of its structure ; the place of each piece and its bearing upon every other part of the machine ; and not then can he right the wrong unless he recog- niges what is wrong. Nor can we phy- sicians intelligently and skillfully right the physical or mental wrongs of our patients unless we first recognize the physiologic error or pathologic condition present. "The sun's rays fall on each separate fruit, which it paints and ripens as though that were its sole business-" Give intense interest to each separate case. It helps to meet the emergency and to save life, and after all, to save life is greater than being great. Mediate Diagnosis. Lieutenant Commander M., U. S. N., aged about fifty-three, was discharged from hospital in or near Boston and or- dered to report in Washington, Came to see his wife who boarded near here. This was in November, 1898. I found him with slight fever, pulse 100, res- piration 22; rales general, asthmatic breathing, with cough. Some muscular soreness. Urine albumous. Tendency to constipation- Treatment mostly elim- inative. He did well. I reported his condition as favorable. In fact, my re- port was so markedly contrary to the "records" in Washington, that on De- cember 24, 1898, Dr. John H. Clark, Medical Director of the Navy, came up to see about him. This was the third time in as many years, so I understood, that he had been discharged from hospitals to report in Washington and each time he had gone to bed again with the same general symptoms, especially the symptoms of kidney disease. The medical depart- ment of the Navy had fully determined to retire him. The records since he entered the Navy were such as to single him out as a proper subject for Bright's disease. During our long talk over the case, remaining with him most of the day. Dr. Clark repeatedly said: "I wish I could see the case as you do for Mr. M's sake, but the records are against him — he'll never be fit for duty." I argued otherwise and held out that he would ultimately be well. Finally, Dr- Clark asked me "How long do you want to cure him?" I answered, "If it were any other patient, I would say two weeks, but with his history, give me August. 1922 ORIGINAL COMMUNICATIONS 427 one month." When Dr. Clark went back fith in sending this report to Lieut. M. to Washington he asked for three says: "The enclosed report of analysis months' leave for our patient — he got made this day shows a most decided im- thirty days. The thirty days expired provement in your condition under the about the 25th of January following, t treatment of your physician and I sin- had Lieut. M. report for duty, I think, cerely hope you will do nothing to give on January 20th, or four days before yourself a 'stepback.' " the expiration of his "leave," in order I argued that the "weak kidneys" to have him escape the inevitable medi- were only relatively weak — not hope- cal survey. I did this because albu- lessly diseased, and based my belief on men, etc., still showed in his urine and the following reasons: I fully ralized that this knowledge 1. The general appearance of the pa- would then and forever end his connec- tient, in my judgment, did not indicate tion with the Navy. He reported as chronic nephritis. stated above, and was assigned to a 2. Because my treatment, almost boat at Key West a few days later. purely eliminative, gave such encourag- From copy urinalysis made November ing results in so short a time. 10, 1898, by Medical Director in charge 3. The lack of a persistent amount of of U. S. Naval Museum of Hygiene at albumen continuously eliminated. Washington, I find "albumen trace-" It 4- The absence of cardio-vascular was soon after this examination that changes. If the renal lesion was chronic he came under my care. and of adequate gravity to cause his re- I sent all the specimens of urine to tirement from sea-faring work, in the Dr. Monte Griffith, The Marragut, nature of the case, there should have Washington, D. C, who handed them been some cardio-vascular changes of over to the late Dr. Wm. Fisher (G. W. sufficient positiveness as to have appre- University Hospital )for examination, ciably raised the general blood pressure. One of Dr. Fisher's reports, which The significance of hypertension as a gave albumen and casts, was dated Jan- precedent or consequent condition of uary 0, 1899. Dr. Griffith in sending both cardiac and renal perversion should his report to me says: "You will see not be overlooked. So far as I could from analvsis that vour patient has kid- ascertain, there had been no knowledge ney lesion. * * * The granular hyaline of high blood pressure up to the time casts are unmistakably from the tubules the patient came under my observation of the kidnevs. The mucous most prob- —there was none during that time, ably from the bladder. I infer your pa- I looked upon the condition as possi- tient's kidneys and bladder are both bly pre-nephritic but certainly not affected. You, of course, will know, nephritic. Hope your treatment mav benefit him." That was in 1898. Lieut. M. has been About Januarv 19th, I had another Promoted twice since then, is now cap- urinalysis made. Concerning the report tain, m good health, and m active ser- is the following letter from me to Lieut. ^^^^- „ , . , Commander M., dated Januarv 24, 1899: The test of time bears me out "Found vour note on mv return home. ^ letter just received from Lieut. Ms Received Dr. Griffith's letter at Char- "ephew in Washington states he is m lotte, N. C, but it is now mislaid. How- good health living in New York and ever, it says in plain language that you ^g^" about 75. are better. Now, I am still of the opin- Intuitive Diagnosis. ion that I can, with your best deter- A- W. T., male, aged three months, mination to get well, direct you pretty Breast fed. Always healthy. Family steadily on the road to health- Keep history good. Patient began to cry at all the records for me — urinalysis, etc. n a. M., February 19, 1905. His moth- Another examination was made by cr could do nothing to quiet him, so Dr. Fisher on January 23rd. Dr. Grif- she sent for me. I got there about 5 428 SOUTHERN MEDICINE AND SURGERY August, 1922 o'clock. Found child still crying. Ex- amined his mouth and clothing for pins Discovered none. Removed clothing and looked for evidence of trauma, with neg- ative result. Heart and lungs normal. Temperature normal- On account of crying it was almost impossible to ex- amine abdomen, but I imagined I could detect a little fullness. Right foot seemed to be a little larger than the left, but gave no pain on moving or handling it. There was absolutely no known symptom nor physical sign to guide in the diagnosis. What was the matter and what was I to do? I antici- pated an inflammatory focus from in- testinal toxaemia, and so informed the child's parents. I ordered antiseptic ap- plication to the ankle, foot and abdo- men, and English calomel and intestinal antiseptics internally. Albumen and orange water diet. I left with instruc- tions to call me early if the patient was no better or worse. Messenger had me up at 5 A. M., February 20th. Found temperature 106 degrees F. and facial, as well as general, appearance indica- tive of intense toxaemia and impending death. Abdomen enlarged. I lost no time in emptying and washing out the colon. The result confirmed my diagno- sis that far ; temperature ran down two degrees. Otherwise could see no change. Continued applications to the ankle and foot. The parents of the child were new- comers— had only been here about twelve months. This was their only boy and a gap of eleven years since birth of youngest girl. I knew what it meant, if he should die ; so advised consultation. Dr. R. E. Wine, of Brentsville, Va., was called. He, too, recognized the gravity of the case and the unusual lack of symptoms. He advised continuation of the treatment. Saw patient next morn- ing an devening- Conditions about the same. Used colon tube and kept up treatment. At 2:30 A. M., February 22nd, was called in again. Abscess had formed on inner aspect of foot and an- kle joint; made free opening, irrigated and dressed wound; temperature low- ered to 100 1-2 degrees and child looked better. February 23rd, temperature 99 degrees ; February 24th, temperature 98 1-2 degrees. Improvement continuous and rapid. The assumption that the abscess in this case was caused by intestinal in- toxication is certainly not unreasonable. Had I made an examination of the pus from the abscess, the finding may have shown a connection between the im- paired intestinal function and the ab- scess. I regret very much that I did not do this. I recall the report (Krokiewitz, etc., Amer- Med., August 20-04), of a croup- ous pneumonia in which, during the first few days, there developed a swelling of the left shoulder point, resulting finally in the formation of an abscess. An ex- amination of the pus revealed pure cul- tures of the Frankel-Weichselbaum dip- lopneumococcus. Very few similar cases have been described in literature. Non-Diagnosis. Was called to see a school girl aged twelve. Very slender and pale. Father an alcoholic and inclined to rheumatism. One brother had been treated for ne- phrolithiasis; one sister for necrosed tibia. Two days before I saw her, on her return from school, she complained of feeling weak and nervous. Could not sleep on account of an undefinable un- easy feeling of distress ; rather inclined to tears. No appetite, tongue coated, bowels sluggish, kidneys moderately ac- tive, temperature normal, respiration 20, pulse 120 and irregular. Precordial uneasiness — cardiac beats visible to the eye. My first thought was that she had been running or romping too strenu- ously but she denied both. Then it oc- curred to me that she might be enter- ing upon the changes incident to puber- ty- The anxious and uneasy feeling kept up for three days. The second time I saw her, I questioned her again about running and romping, then sh» told me that she and two other girls were "jumping up and down" on a board over a rather deep ditch, when the board broke and precipitated them sud- August, 1922 ORIGINAL COMMUNICATIONS 429 denly to the bottom As she was so He had cursed the serpent, — he had very fail, I made the diagnosis — trau- cursed the woman, and put eternal en- matic shock to the nervous system and mity between her seed and the seed of heart. Three days later (seventh day the serpent, — he had cursed the man of sickness) I found the ankle joint with a curse that made it necessary for ' some what swollen and tender, with a man to look out for himself to the extent slight rise of temperature. This joint of forgetting the interests of others, if was better at my next visit but a knee necessary, that he, himself, might live, was tender and swollen ; temperature Then, — can we not almost imagine the still up. I then inquired more closely scene, — God in this outburst of indigna- into her previous history and found that tion at sinful ingratitude — was still not she had quite a severe attack of rheu- done with cursing and he further said to matism when three years of age. Now, Adam, "cursed is the ground for thy had I done this at my first visit, as I sake; in sorrow shalt thou eat of it all should have done, I would have put her the days of thy life ; thorns also and on appropriate treatment. As it was, thistles shall it bring forth to thee ; and seven days' time had been lost. The thou shalt eat the herb of the field." cardiac condition grew steadily worse. "Unto Adam also and to his wife did the I lost my patient. Lord God make coats of skins, and cloth- ed them." The penalty of sin made the offenders suffer and established strife, STATE INSTITUTIONS AND MEDI- ^>^^°^^ ^"^ ^^"^'^^^ ^ff ^^"^ ^^^^'^ ^f CAL EDUCATION. supremacy. The penalty for sm made the innocent animals, also God s crea- By M. L. Townsend. M.D., Charlotte, N. c. {^resi, suffer, for with the curse man was The dedication of these new buildings not robbed of his exalted dominion over marks a great event in the history of the the earth, and all things else therein, so State of North Carolina. he slew the innocent for food and used Today North Carolina elevates herself their skins for clothing, higher in the scale of civilization than In this outburst of righteous indigna- ever before. tion all nature's pre-existing laws were This day is a milestone on the road changed, and there was then established toward the ideals of Christianity and the one dommant law of all nature— ihc goal of all progress. " "The survival of the Fittest. The „,, ■ . 1 /- ^' •^„.-,. „.«viri weak must give way to the strong and When sm entered God s virgin world, j +i, „„^.,;ci,^^ ^c ofo,> TT .1 J iu ;,, all progress used the vanquished as step- rhe curse He then pronounced on the sin- ". ^ f . ,. I „„j i,;„i, ' , , . , f ^„,v. ,,foi loivc- ping stones to mount higher and higher. ner changed natures fundamental laws. ^ ^ . . , ,, ^,x^r.f ^^^ o,-v. T.,>^r.,-vM>af ..r i.1 ^ £ 4.\, f i,„u +v,^„ Certainlv the advent of sm precipitat- In the sweat of thy face shalt thou , ' i • v i ^ J ^^■^\l, 4- , f^ +v,^ ed a curse which made a sorry mess of eat bread, 'til thou return unto the " . „.^,,i^ fio.v,f,-v.o- .,n-fV, ,„ ', n „ 1 -u^ • ^,,1 things with all the world fighting — with ground : thenceforward the siniul, .. ^ <- i • i^ ^ ^u j -i cursed man must ever work and fight '^-^y man for h.mself and the devil and struggle until, overcome by death, ^^^ ^he hindmost. his body returns to the dust from which And so the world went on, until m i^ ^^^^Q this chaotic maelstrom there was in- ' " .J , ,< , 4- ». +u ,^ iected a new order of teaching, the pur- Unto Adam's "sou -mate -the wo- ^ ^,^^ ^^ , ^.j ^^ ^^^ man-he said, 'will greatly multip y P , ^^ ^^^^^, ^^^^ ^^ thy sorrow and thy conception ; in soi- ^^^^ ^.^^ ^^.^^^. row thou Shalt bring forth c-h.ldren ; and ' ^^^ ^^^,^^ ^^^ ^^^ y^^^^^^ ^^^^ thy desire shall be to thy husband and ^^^.^^ ^ ^ ^^^ alleviating the hejhall rule over thee. ^^.^^ ^^ ^^^ ^^^^^^ ^^^ overcoming sin's , _ ,. terrific consequences. ,„.7:rl.': ';i;,f:™;ri' '^'^:::^V::^Z CUn^i^Hy means evolution and evo. School, Kinston, N. c, April 13-14, 1922. lution means constantly getting better. 430 SOUTHERN MEDICINE AND SURGERY August, 1922 Christianity teaches the strong to extend is violating the trust imposed in him and a helping hand to the weak and by lov- he is in the same class with those whom ing help, encouragement and cultivation, experience has proven it is wise to re- lift them up to higher levels of strength strain, at state expense, in a state insti- instead of pushing them down and un- tution called a penitentiary. He and der foot. they have not accepted the new order This day is an epoch in Christian prog- of teaching but, following the curse for ress, for here we see a great state ex- sin, are, like Adam, living every man for tending a helping hand, for the purpose himself and the devil for all. of lifting up, in brotherly love, the ones The world is getting better, selfishness who need a state's help and protection, is less apparent, and crime is on the This greatly bettered institution wane — thanks to this new order of which we see today is only one manifes- teaching — but the millenium has not tation of the execution of the Christian come — yet. Until it does, criminals must teaching that we are indeed our broth- be restrained, (and a criminal is only er's keeper. one who places his own selfish desire After all, a democratic state has abso- above the rights of any one or every one lutely no other function or excuse for else)— the physically and mentally weak existence, than to use its good offices must be helped by the strong and this and its combined strength for the bet- can only be done through the agency of terment and the uplift of each and every state institutions, one of its individual and component cit- Those who ivill not recognize the izenship. In a democratic. Christian rights of others must, for the sake of commonwealth, the interest and welfare others, be restrained so no damage can of the individual is not submerged in be done. Those who would but cannot, service to its ruler, but the individual because of physical or mental inferior- interest and welfare is served by serving ity, recognize the rights of others must the common good of all. likewise be restrained and at the same This is not Governor Morrison's state time, be treated for the correction, in so and this is not Dr. McNairy's institu- far as possible, of their defect so that tion, but Cameron Morrison and C. they can be returned to society as no Banks McNairy are servants of the state longer a menace but a help, for the execution of the will of the peo- There is another class wko can and pie to the end that humanity may be do recognize the rights of others and made better, the weak made strong and therefore need no restraint but whose Christian civilization advanced. defect or infirmity makes them a men- As public servants no men have ever ace to others and who must be cared for been more conscientious in the discharge ^y the state for the protection of others, of the duties they have assumed than Then, there is that fourth class who these men and their lives and works will are m no way a menace to society but be an inspiration to all men everywhere ^^'^o are helpless and suffering and de- to nobler deeds and more unselfish serv- serve for their own best good the helping ice. Would to God that the Governor -and of the state. of every state and the administrator of We have then the penitentiary, the every state institution could be over- asylum, the sanatorium and training whelmingly imbued with the paramount school and we have the charity institu- idea that their official life must be one tions including the county homes, etc. of unselfish service to humanity. "May But the duty of the state does not the time speedily come when no public end with these. The people to be happy oflficial may get his tables reversed and and prosperous must be educated and assume the attiude that the office should must have advantages which can only terve h'm instead of he serving the of- be obtained by collective effort on an fice. Should he assume this reversed enormous scale, attitude it is then at once obvious that he There must be state institutions for August, 1922 ORIGINAL COMMUNICATIONS 431 educating the young, and institutions for cation is completed will come back to demonstrating to the old, better ways of North Carolina and care for the state's working and living — there must be pub- sick people. lie roads, and public mail service. There But most unfortunately, and sense- must be a public health department to lessly, too, it seems to me, the state is teach health principles and also, if nee- spending this money, only to find that essary, to compel those who will not or when these students are ready to enter, cannot recognize the rights of others, to there is no place where they can find ad- refrain from jeopardizing the health of mission and thus the money has been others by unsantiary acts and habits. lost. In North Carolina, all these duties of It seems strange, too, that the more the state, so far mentioned, are being money the taxpayers of the state are done in a most strikingly efficient man- spending on the State University the ner. We challenge any state to prove fewer doctors are provided for the care they are doing more along these lines of the citizens of the state when they than North Carolina. Her people are become sick, spending through state administration Yet this is true. millions of dollars for better roads, and There are only two states in the union better schools for better hospitals and with so few doctors per population as a better Caswell Training School. The North Carolina. There is no provision state is able and willing to do and is do- within the state for educating more, ing all these things which it is right and hence, an already very lamentable situ- proper for a great state to do. And not ation is growing worse each year, only that but she stands ready and will- The annual death rate of doctors is ing to do anything else which she can do about 50. The state is increasing in when it is shown that there is a need, population at the rate of 35,000 each And there is a need. Perhaps the most year, which means that the present crying need today, is for a thoroughly shortage is increasing 100 doctors annu- equipped and eflficient finishing school in ally. The average in the United States North Carolina for students of medicine, is one doctor for every 720 people — but It is an anomalous sort of situation in North Carolina it is one for every for an institution like the University of 1,100. North Carolina to be fitting young men North Carolina will need for many for the study of medicine by general years to come a minimum of 150 new academic instruction and by the so-call- doctors, every year, to replace the death ed pre-medical course and by two years rate, take care of the increasing popu- of actual study of medicine, and then lation and catch up with a normal ratio have these medical students, prospective in order to properly care for the health and actual, find it impossible to matricu- of the state. late in a medical college because the Certainly it is the duty of the state to medical colleges of the United States take some part at least in making pro- have in recent years been reduced from vision for the adequate care of her sick 162 to 96 and because also the remain- citizens by seeing to it that competent ing colleges have been compelled to re- doctors in sufficient numbers are scat- duce their matriculants. (Today there tered throuhout the state. are only 3,000 graduates as against Some students in the state institutions 5,500 formerly.) are given such instruction, at state ex- It is indeed a queer situation for the pense, as enables them to go out and State of North Carolina to find her- diagnose and treat diseases of plants, self in. It may be more difficult but it is like- The taxpayers of the state are spend- wise much more important for the state ing their money every year to prepare to train the necessary number of yaung certain young men within the state for men in the diagnosis and treatment of the study of medicine in the hope that human ills, these young men after their medical edu- The situation has reached the point 432 SOUTHERN MEDICINE AND SURGERY August, 1922 where something must be done and the faith and confidence in the ones who slate, seeing- this need, is not going to taught them, and just as soon as wealthy be backward in doing the right thing. John Doe has a serious toothache in his It is to the physicians, on whom the heel young Doctor Young bundles him right to practice medicine has automat- up and carts him away to a former ically brought with it the responsibility teacher in the city where he went to of being leaders in such matters, that school. That is all right, but, it is North the pciple are looking for the proper so- Carolina money that pays the bills, lution. The matter of establishing a g^ery time you let a North Carolina finishing medical school in the state youth leave the state to secure his fun- should not be gone at hastily, but the damental education in medicine you tap need, the purpose and the plan ought to North Carolina's monev box and estab- be submitted to the cold, critical judg- jigh a leak that will continue on and on. ment, of the physicians, the educators, who will deny the fact that if these the leaders and the people. Like good j^aks could be gathered up and saved at roads or anything else worth while, it j^ome, the total would not only pay the will repay a hundred fold. interest on the investment but would in Just one ther point : The intoxication addition yield a handsome dividend, of urban life is contagious, and also the ^ fundamental essential for medical standards of exchange are different so education is clinical material, that is sick that the young man, although rural bred ^^ ^^ ^^^^ ^^^^ ^^^ ^^^^ ^^^ -^ and reared, will hesitate, after three or ^^^ p^^ofession to treat their ills without four or five years spent m a great city, ^^^^^,,^^^ f^^ the privilege of doing so to return to his native heath and heather. ^^^^^^^ ^ ^j^^^ ^^ ^^^^^^^ ^f^^^, ^^^^^_ and will let his brothers and cousins suf- ^^^^ jjere again the state is the win- fer unattended, while he feeds on the ^^^^ ^^^, ^^^ necessary 200 or 300 bed husks m a distant city. hospital, wherever it might be located The present necessity breeds the pres- ^^.^^^j^^ ^^^^^^^^ ^^ ^j^^^ ^^^ ^^^.^^ ^^^ ^^^^^ ent tendency to locate m arge centers. ^^ ^^^^. ^ ^^^ ^ . ^^^,^^ ^^^^_ If these young men could be thoroughly lina monev at home she would also be and completely educated within the state ^g^^jj^g ^^-jg ^^^y ^^ ^^^ citizenship they would remain m the state and sup- ^^^.^^^^^^ ^^^^ ^^^^^ ^^ ^^^^ ^^^1^ ply the need where the need is greatest, p^^^bably be unable to otherwise secure Durmg the very brief existence of _the treatment) and be having this number University Medical School in Raleigh, restored in the minimum time to normal young North Carolinians were graduat- ^^^^^. , .jty. Not even good roads ed whose names are know by medical .^ould pay the state as handsome returns men throughout the world. Names you know of men you love. as would a thorough and complete fin- ishing school for students of medicine. I say agam there is a need and I add ^^^ .^ .^ ^^^^^^ ^^^ ^^^^.^^^ ^^^^ -^ that it IS also expedient. Money will be -^ ^^^^ extremely practicable. The nec- needed thats true but money can be ^^^^^^ .^^^ j^ ^^ ^^pp^^ ^^^^_ had-there is plenty of money. It is ^j^.^t ' clinical material could be main- not a matter of money but only a matter ^^.^^^^^ .^ ^^^ ^^ ^^^^^^^ ^^^^^ ^^ of deciding whether money spent tha ^o.ooO or more within the state. The way IS a good and profitable investmen ^^^^^ ^^ ^^^^ .^^ ^^ ^^ ^^. -If such investment will yield as gooa ^^^^^^ ^^ ^^ ^^^^^^ ^^^ ^^^^ ^^^^^.^^ ^^^^ or better returns than if invested other- ^ ^^^^ ^^^ ^^^^ wise. At present such young North Caro- ^, , ^ ' ,. ,, , , ^ linians who can find admission, go out of ^ ^^^^^ Carolina can well be proud of the state and ^udv medicine (and in- her achievement today as she views this c^dentally many of"them stay out) and sP^endid provision for the proper care cairv with them North Carolina money ^^ ^^ese wards of hers. North Caro- to pay the bills. Those who come back h'na's face is forward and she will never home to live, bring back with them a look back. M. L TOWNS END, M. D. C. MONTGOMERY, CHARLOTTE August, 1922 EDITORIAL 433 inally careless midwife has introduced SOUTHERN MEDICINE AND SURGERY the cause of this agonizing death and a D ui- L J »>. ., L u ruined home. Published Monthly by the r\ , ■ ^^ ^^ i • Once upon a time all epileptics and m- Charlotte Medical Journal Company sane were said to be possessed of de- mons but later their accusation was in a /. c. MONTGOMERY, M. D. \ ^''''«''» vvav modified by an equally supersti- tious answer which said "it just hap- pened." Not content with this reasonless ex- "Read not to contradict and confute, nor to planation Cotton and Reed hit upon the believe and take for granted, nor to find talk j^g^j ^f f^^^^l infection, an idea sponsored and discourse, but to weierh and consider. — . . ,, ji • j- n , -n-n. Francis Bacon. originally SO enthusiastically by Bilhngs as a cause for so many clinical pictures, and have contributed and do contribute to this cause the greatest number of con- Give Abnormals a Fair Chance. vulsive states and mental abnormalities. ^, . ^ , This attitude of these eminent men is There IS a cause for every event,- ^^^^ commendable and is certainly there is a reason for every condition. ^^^^ ^^^^ ^^^^^^ ^^^ Christian than is The man who boldly proclaims, when re- ^^^^ ^^ ^j^^^^^ ^^^^^ ^^^^ ^ ^^ ^^ ferring to any unusual condition in na epileptics and some happen to be insane. ture that it just happened to ue is r^^^ ^^^^^^^ ^^ ^^^.^^^ ^^^ .^ ^^ ^^^^^^ boldly proclaiming his ignorance .ut is ^^^^ eause, and then apply themselves to doing so in a manner that smacKS of .^^ eradication and to the mitigation of quackery because he insidiously implies j^^, effects that if there was a reason he would 'otherwise great minds have ridiculed know It and hence claims more fo. him- ^^e idea of Cotton and Reed that toxins self than he possesses. How much more ,^^,1^ ^e the cause of convulsive seizures hones It would be to frankly say I ^^^ ^^^^^al derangements. Otherwise don't know why For all too many generations we have brainy men once ridiculed Koch's idea that a spirillum in water would cause to complacently said this child happens .Solera. One eminent man offered o be epileptic, and that person happens ^i^j^j, and did drink a test tube full of to be insane. this child happened to dock's infected water. He did not die have club feet and tha mother hap- ^ut the many days of the most extreme pened to have eclampsia. iHn^gg converted him to Koch's hvpothe- Like predestination and the teachings gjg ''!^«"'f "Tu"'"^^ - ' ■'"''^/" '^^^'^"''^ ^^ "^ ^""P^" If nialaria plasmodii can produce rific to the pangs of grief when some one chills with such violent convulsive near and dear is gone. But while for twitchings and muscular contractions ^his It must be commended it must at the and followed with wild delirium why ;ame tmie be condemned, as dangerous may not other bacteria or toxins produce m the extreme Suppose we picture a other forms of convulsive seizures and hyrothetical (?) case. The wife and mental abnormalities, mother IS gone. During her last hours Unquestionably they do, and this has .' ^G su.f.-red with all the tortures of been proven in too manv thousands of juerpfral sensis. The minister in a cases by both Cotton and Reed to be i-:udable effort to spread a soothing balm longer disputed. and console the ones who suffer the loss The human vision, however, when says, ihe Lord in His infinite wisdom once focusel on one particular spot fails and Kondness has seen fit to take her to see the side issues or other equally im- away. While the Lord in mute com- portant objects. All foci of infection l^nm^f . n''"n !J the accusation but should be sought and removed when knous full well that an ignorant or crim- found, but if our enthusiasm leads us 434 SOUTHERN MEDICINE AND SURGERY August, 1922 blindly on searching for one and only ly. one cause, while we pass by a myriad Ultra conservatism and blind adher- other causes just as real, then the fault ence to established customs is just as is ours. wrong and possibly worse, than ultra When a man is so blindly determined progressiveness which is so progressive that a focus of infection is the cause that that it smacks of venturesomeness. For his experimental search leaves an epi- the doctor it is doubly true that "there leptic toothless, tonsilless, and indeed al- are none so blind as those who won't most completely eviscerated then such a see,'" while the ventursome doctor is man has lost his persepctive and needs carried by his enthusiasm along some counsel and restraint, not to curtail his special line into meddlesome medicine usefulness but to minimize the danger which often results in actual detriment of his over enthusiasm. to the patient and reacts most unfavor- Probably the greatest innovation of ably upon the medical profession at all time will be the Diagnostic Survey large. which Dr. Reed advocates in his article Today it seems that specialization is in this issue of Southern Medicine and running rampant and has become an Surgery. Under existing condtions, actual obsession in the minds of medi- neither the epileptic, the insane nor the cal educators, and the entire medical criminal are getting a fair and honest profession. It is axiomatic that the deal. The Christian civilization of a man who specializes on one particular Christian commonwealth demands a phase of the riddle of disease and its Governor's Advisory Board to pass on relief is more proficient in that particu- criminal responsibility of all those who lar thing than the general man, so there violate the state's laws, and demands a must be and always will be specialists, diagnostic survey by a competent group There are three notable causes for of diagnosticians who will endeavor to the pendulum swinging so far toward find out in each individual case the cause specialization. Formerly there was an for the epilepsy or the insanity and find- inadequate supply and hence a real ing the cause will also recommend or ex- need. Phenomenal advances made in a ecute measures for its correction and the relatively short period of time upset the mitigation of its effects. existing order of things and there is a lack of complete readjustment. While the third, and without question the most Fadism in Medicine. powerful, influence is the greater remu- neration and prestige which belongs to No doctor will be held guiltless who the man who does the more spectacular attempts to practice medicine without things. being familiar with, and willing to util- We are prone to forget that many of ize, the various, approved, auxiliary the real outstanding benefactors of the methods for making a diagnosis. human race were not specialists but Likewise no doctor will be held guilt- only general men with clear vision and less who allows his interest in, and en- keen understanding, thusiasm for one special trick to over- Koch was not a specialist but an un- shadow discretion and blind his perspec- known, hard-working general practition- tive. As important as is the test tube, er in an obscure village in Prussia when microscope and X-ray, a stubborn de- he demonstrated both the tubercle ba- pendence on their findings alone would cillus and the cholera spirillum, often be suicidal and homicidal. Jenner, whose vaccination has no Doctors are human and it is a trait doubt saved more lives than any other of humans everywhere to follow fads one discovery, was engaged in the gen- which often lead to extremes — but cer- eral practice of medicine, tainly no profession and no class of hu- Ephraim McDowell, whom the women mans, need more than doctors, to sit of the world will forever bless, was just steady in the boat and make haste slow- a hard-v.'orking, country doctor among August, 1922 EDITORIAL 435 the pioneer settlers at Danville, Ken- agree that our entire educational system tucky. should be directed solely to that one ob- Pasteur was not even a physician at jective. The world needs broad-minded all but a chemist and yet Pasteur made general practitioners and our medical modern surgery possible- schools need broad-minded, experienced Sayre was a general surgeon but he teachers in the fundamental branches, became the father of the orthopedics of The theoretical teacher, be he ever so the world and the activator and teacher scientific, must, figuratively speaking, of Hoffa, Lorenz, and the other notables deliver his lecture in a monotone with in this branch of medicine. no emphasis on the important points, So far it has been the men with a because he himself does not by experi- general education and a broad outlook ence know which points really are im- upon life who have discovered most of portant and essential, the worth-while things and the so- If every eye is fixed in a microscope called specialists have not made their who is there left to indicate the espe- fair share of contributions along these cial spot on which to focus this intense lines. and magnified vision. The picture of It is very lamentable that our medical an elephant obtained only through a colleges have practically ceased to train microscope would certainly be mislead- and develop general practitioners but i"S- instead are turning out specialists and This sorry plight of affairs can only research workers. All too many pro- be obviated if every medical student is fessors have disdain for, and look with given the necessary practical training, contempt upon, the general practitioner, and with it the necessary mental atti- with the result that the potter's clay in tude which will put him m position to their hands for moulding turns out al- become a good general practitioner, most a snob whose ideals are beyond Down in the bottom of its heart this realization i-"^ ^vhat the profession wants and what Specialties can only be successful in the public want and need but-it is a trait ot human nature to follow fads centers with an adequate population to draw from and in such centers, even now already, the specialists have be- come so crowded that many of the younger men are finding it almost im- possible to make a living in the specialty which often leads to extremes — even fadism in medicine. 'sychology in Tuberculosis. for which they have spent their all in To help tuberculosis patients, it is preparation. This, too, while the pub- necessary to understand them thorough- lie at large is facing th-' real danger, ly and equally necessary that the pa- especially in the rural districts, of be- tient should have absolute confidence in ing unable to secure the services they both physician and nurse, need because the medical schools are No one should undertake to advise turning out only specialists instead of such a patient until, by one or several general practitioners. intimate, confidential talks, he has be- The world needs specialists, and needs come thoroughly acquainted with this the vry best it can get, and no one individual and knows the personal pe- should be denied the right to develop culiarities, personal habits of living and the talent that is within him. So the thinking and the things in which he is United States must have a President interested. and needs the best man it can get, but After this first step it is then essen- there must also be "hewers of wood and tial to explain minutely the reasons for drawers of water," and although every the necessity for obeying certain rules male child born in the United States and regulations of life to the end that whose parents are American citizens is the patient may co-operate to the full- a potential President, yet we can hardly est in curing himself or herself It is ^36 SOUTHERN MEDICINE AND SURGERY August, 1922 hardly to be expected that this co-oper- ation may be efficient unless the patient knows why he must do these things. Win his confidence and his heart and this is only possible by actually being vitally interested in his joys, sorrows, cares and hopes. There seems to be no definable reason why some pitients get well and others do not, but it is absoluti'ly certain that the patient who will co-operate intelli- gently has a much better chance to get well, and securing the proper mental attitude is the very first and most im- portant consiedration. Next comes happiness and content- ment— freedom from cares and worries, and maintaining a congenial environ- ment. As important as pure air for the lungs is an atmosphere of optimism sur- rounding the patient. Climate, per se, may or may not be important but climate as it affects the mental status is of tremendous import- ance to the tuberculous person. The more beautiful the surroundings and the more cheerful the weather the greater are the good results — therefore change is often helpful. For the one who loves the mountains, a mountainous surrounding is best but always it should be where the days are not cloudy and depressing. There should be the maxi- mum sunshine for consciously or sub- consciously the absence of sunshine is depressing which is quite as detrimen- tal as the absence of the sterilizing ef- fect of the sunshine itself- For exactly the same reason the liv- ing quarters should be bright and che'i'- ful, open and free. The patient must be shielded to the extent of human possibility from worry and responsibility, whether financial, domestic or homesickness. Hence many patients are better kept at home while many others are better to be sent as far from home as they can go. In in- stitutions the mingling of .sexes is ap- proved by the best authorities, because thus they are happier and it creates a more normal atmosphere "Men in groups becom'^ too rough and women too catty." The fact that the duration of the treatment for tuberculosis extends over a long period requires the utmost pa- tience, endurance and tact on th»' part of physicians, nurses and attendants, for once confidence is lost and optimism broken a serious damage is done. Per-, haps with no class of sick people is it m.ore important to retain th'' individ- uality and to know the patient by his own name rather than merely as Pa-1 tient No. 147. The very first realiza- tion that he is known by his doctor and nurse only as Patient No 147 wounds his sensibilities and destroys that confi- dence and personal acquaintance which it was so important to establish at the first. Some persons respond to treatment while others do not and we wonder why. Perhaps the answer may be found in a more careful study of the psychology of thi' patient and a more careful analy- sis of the way the case has been man- aged. SURGERY A. E. Baker, M. D., Dept. Editor Moynihan and Walton — On the Treat- ment of Gastric Ulcer. (Lancet, 1922, ccii, 267.) Hemorrhage and perforation are the only characteristic manifestations of an acute gastric ulcer. If a gastric ulcer is frmnd at operation or autopsy, it is not necessarily accountable for symptoms thi't have been present for months. The relationship between acute and chronic ulcers is not definitely known. Chronic gastric ulcer is rare. Its inci- dence is half that of duodenal ulcer atid it occurs twice as often in men as in women. Incorrect diagnosis is respon- sible for many useless gastro-enterosto- mies, the patient being made worse in- stead of better. Following the operation jejunal ulcer may develop and add to the discomfort. There are but two methods of making an unequivocal diagnosis of gastric uicer : by means of the roentgen- ray and by inspection at operation. August. 1922 EDITORIAL The medical treatment given at the j resent time is woefully inefficient; for the rich it is possible, for the poor it is scarcely obtainable. The preparation of the patient for op- eration is of great importance. In addi- tion to routine examinations, the teeth and sinuses should be examined for foci of infection and the patient given large quantities of glucose or a direct trans- fusion of blood to overcome the effects of weakness, wasting and dessication. The surgical procedures which have been adopted are the following: (1) gastro-enterostomy ; (2) excision of ul- cer; (3) gastro-enterostomy combined with excision; (4) gastro-enterostomy combined with destruction of the ulcer by means of the cautery (Balfour's op- eration) ; (5) median resection of the stomach (sleeve resection) ; (6) gastro- enterostomy combined with jejunostomy (Moynihan's operation) ; and (7) par- tial gastrectomy. Gastro-enterostomy has been the most frequently performed of these opera- tions. Two views are held as to the manner in which it produces its results. According to one, it is purely mechanical in its effects, giving relief by preventing retention, since it is most efficient in cases in which marked obstruction is caused by a scar at or near the pylorus. The second view is that it possesses a "physiological" action by alkalinizing the gastric contents. In Moynihan's opinion there is no reason for the belief that an alkaline medium favors the healing of a gastric ulcer. It is an interesting fact also that when gastro-enterostomy has been performed for duodenal ulcer a gastric ulcer may develop. Moynihan believes that the procedure should be reserved for cases in which the ulcer is distal to the open- ing to be made, in which no reasonat)le doubt can be entertained as to the be- .nignity of the ulcer, and in which the patient's condition renders a more ex- tensive operation too dangerous. . Sample excision of the ulcer is unsuc- cessful because it is followed by obstruc- tion due to the contraction and distor- tion of the stomach or because the ulcer lecurs along the suture line. Gastro-enterostomy combined with excision does not give an adequate num- ber of satisfactory results and is by no means as good as Balfour's operation. Balfour's operation consists of the de- struction of the ulcer by means of the actual cautery and the performance of a gastro-enterostomy. According to the records at present available, this opera- tion is simple, safe, and satisfactory in respect to after-results. Next to gas- trectomy, Moynihan prefers the Balfour operation. Median resection is sometimes follow- ed by recurrence along the suture line as well as contraction and stasis of the stomach. In the authors' experience gastrec- tomy is the most satisfactory operation. The mortality is low and the results are as near perfection as possible. " No re- currence has been seen after this opera- tion. The mortality is less than 2','. Conditions identical with acute gas- tritis and gastric erosions may arise in the duodenum. For these no operative treatment should be undertaken. The only possible exceptions are cases of se- vere repeated attacks of haematem^^sis in which another hemorrhage would probably prove fatal. Under such cir- cumstances no time should be wasted in looking for the lesion. The patient should be anaesthetized, given a direct blood transfusion, and subjected to a posterior gastro-enterostomy. The re- sults obtained by this method in Wal- ton's experience have been satisfactory. Perforation is extremely rare in acute gastric ulcers. If it has occurred, the ulcer is chronic and simple suturing will not effect a cure ; hence a gastro-enteros- tomy should always be performed- Pyloric and duodenal ulcers are satis- factorily treated by posterior gastro- enterostomy. There are two possible ob- jections to this treatment: (1) Carci- noma may arise at the site of the ulcer ; (2) the operation may be followed by gastrojejunal ulceration. Very often a carefully taken history will reveal the presence of a malignant change. If there is any doubt as to the lesion, a partial 438 SOUTHERN MEDICINE AND SURGERY August, 1922 gastrectomy should be performed. and could not see and would not believe. Most authorities place the frequency Observation of the object is one thing; of gastro-jejunal ulcers at 2 per cent, understanding the phenomenon is an- The mortality of a partial gastrectomy other. The arctic tern, the greatest seems to outweigh the danger of a gas- traveller the world has known, spends tro-jejunal ulcer. Ulcers on the lesser its summers, so the birdman tells us, al- curvature are cured by gastro enteros- most within the shadow of the north tomy in only 40 to 60 per cent of the pole, but it winters in the tropics, more cases. than 10,000 miles away from its natural Hour-glass stomach is much more home. Once each twelve-month year it common in women than in men, is usu- "^^kes the round-trip journey of more ally due to a simple ulcer, and is very ^^an 20,000 miles, guided unerringly often associated with ptosis. For this through objectless space, often m im- condition the choice of treatment lies penetrable darkness, by some never-mis- between. (1) knife or cautery excision ^akmg, god-like sense that we neither with gastro-enter ostomy, and (2) par- Possess nor comprehend. The carrier tial gastrectomy. Excision alone is in- P^^eon, boxed and confined, and so ship- sufficient. If there is any suspicion of P^^ ^^ross the continent, immediately malignancy, partial gastrectomy is, of "pon release, raises itself in spirals clear course, the operation of choice. ^^ ^^e ignorance of earth, as if it would commune with some god in the bound- less ether, and then, straight as an un- refracted ray of light, goes with the speed of a thought to its own home. The cat, the cur, the pig, the stupidest of ~ , ui 1 V.4- -v, +v.i-= animals, makes its way through woods Chance probably plays no part m h s ^^^^ ...jiderness and fields back to the IVtental and Nervous James K. Hall, M. D., Dept. Editor universe in which we find ourselves, even though at times disorder and tur home from which it had been taken. Yet we talk about and write about orienta- bulence seem o prevail. The law of ^^ .^ ^^^ j^^. ^ ^^^^ ^^ ^^^^ ^^^_ cause and effect must reign. Our vision ^ ^^^^^^ ^^ ^^^ ^^^^^^^^ ^^^ IS dim: our understanding limited; our ^^^^^ ^^^ compass for knowledge of bias and prejudice great; we are so ^^^^^^ ^^^ ^^ ^^^ ^^ ^.^^, ^^ much a part of It all-m our opinion unnumbered how inferior are we most of it-that we are without per- j^ comparison with the beast of the field spective, and because we are unable to ^^^ ^^^ .^^^^^ ^^ ^^^ ^^^^^^j ^^^ ^.^^^^ we know, how much we pretend see ourselves with detachment we can- not see ourselves as we are, nor can we understand the relationship existing be- . ^he purpose of the nervous system, tween ourselves and the things around including the brain, must be to give one us. Through egotism we have pedestal- fPPreciation of ones environment and ized ourselves, set ourselves above and ^o enable one to register reaction to that apart from all the other animals of the ^™°f ^^"*- The environment includes kingdom, and always we have tried, but f ^^at has existed m the universe since always in vain, to absolve ourselves from time began ; it includes what is; and it the effects of the laws of Nature that "^^f embrace also whatever the mdivi- are in dominant control over all animals ^^^\ }'' imagination may inhabit his in the universe. Our religion, our laws. world of the future with. To all these our egotism our ignorance, all tend to myriad things, in ways without number, set us apart in our own opinion from the individual must react This reaction the influences of laws that prevail ^« ^J^^^. P^^f^ble through that physical around us and about us and within us mechanism known as the nervous sys- and will prevail after we have been ^^^- Portions of it in the tenderest con- smashed and pulverized and have gone ceivable threads insinuate themselves our forgotten way because we were blind out to the surface and then end in such August, 1922 EDITORIAL 439 a way as to enable US to obtain that pecu- disturbance the more likely to come? Lar information about the world around Despair, disgrace, humiliation, shame, us through what we call sight and hear- fear, terror, war, debt, ungratified de- ing and touch and taste and heat and sires, a carping wife, a shameless son, cold and feeling in general. From birth a disgraced daughter, chronic hunger, to death — after death, also say you? — political excitement, a drunken husband, along these little slender fibrils — billions the dread of hell, poverty, friendlessness, and trillions of them — into the brain homelessness, the carnage of warfare, messages are constantly pouring, day repression, debt, worry, anxiety, dread, and night, asleep or awake, forever and imprisonment, impending electrocution always, the messages come. Upon the — these states and myriads more in this mind falls the burden and the responsi- complex life of ours, may they not also bility of receiving them or rejecting be causes of insanity? Who would make them, of interpreting them, of under- light of heredity. Does not the grain of standing them, if they can be under- wheat bring forth the form and the stood, of deliberating about them, of at- qualities of its ancestors? Does not the tending to them, whether they be of cattle breeder rely upon the laws of sight, of hearing, of sound, of taste, of heredity in adding to his herds and his touch, of hope, of despair, of joy, of sor- flocks? Is it expected that one may row, of death itself. Through this nerv- gather figs from thistles? Does the Af- ous mechanism the individual is brought rican mating with the African beget an into relationship with all else in the uni- octoroon? verse— with God, with the devil, with These wonderings and these wander- things animate and things inanimate, jngs are the writer's reaction to the with things that were and things that reading of two articles in this number are and things that are to be. Is there of this journal— the one by Dr. Henry in the universe such another mechanism a. Cotton entitled 'Tocal Infection the on which so many forces and such varied Cause of Much Mental Disturbance," the influences impinge? Is there any other other by Dr. Charles A. L. Reed, entitled apparatus so susceptible to so many in- "Diagnostic Surveys by Diagnostic Com- fluences? What man-made thing can missions for Asylum Populations." Dr. see and hear and smell and taste and Reed looks upon epilepsy as a physical fear and hope? convulsive reaction to chronic physical Is it wonderful, 0 man, that such a infection. He joins Dr. Cotton in view- mechanism should sometimes become ing insanity as a mental manifestation disordered and that its activity should of long-standing infection of some por- seem abnormal? Is it likely that out of tion of the body. The world is a big the boundless universe one influence and thing; these two eminent men should be one alone should be able to put it in dis- able to see in it more than microscopic array ? Toxins ? Potent enough they germs. The mind is the one thing in the are, to be sure, to drive life out of the world susceptible to every conceivable body, but puissant are other things as influence. It is not reasonable to sup- well. Is insanity caused by toxins, and pose that toxins alone are capable of put- by toxins alone? If the brain be in com- ting it in disarray. munication with the world beyond itself But it is well for emphasis to be placed through a hundred blood tubes it must upon the probable fact that Mind, what- be in relationship with its environment ever it may be, has its seat in the phys- through a billion filaments of nervous ical being. Mayhap we think not only tissue. Substances reaching the brain through the medium of the brain, but by trom blood and lymph are from a nearby the aid of every other cell in the body as and limited field ; impulses pouring into well. It should be remembered also that the brain along nerve fibres are caught the physical body is the most immediate up out of the very boundlessness of the and intimate portion of one's environ- universe itself. From which source is ment, and that disorders in the physical Urology A. J. Crowell, M. D., Dept. Editor 440 SOUTHERN MEDICINE AND SURGERY August, 1922 being are apt to make themselves known tndinal cut through the bone is made by in the mental and in the nervous domain, the circular saw, as is also the horizontal For this reason and for the reason also cut of the outer half, while the horizon- that mind must make manifest its func- tal cut of the inner half is carried out tioning through the bodily mechanism, by means of a Gigli saw. the human physical machine should be The point of election for the osteotomy kept in good order. One can live in is not the place of the deformity itself, more comfort and live more efficiently if but a point at some distance from it, one is lodged in a sound body, whether mainly because of the danger of infec- one be nervous or stoical, sane or insane, tious material harbored in the callus, ^ and also because of the insufficient osteo- genetic qualities of the callus. The max- imum lengthening cannot be obtained in one sitting, but must be attempted grad- ually. Putti obtains it in from 20 to 30 Dr. F. M. Hodges, Richmond, Va., in a ^]^^ . ^ .u ■ ^u paner printed in the American Journal For the purpose of lenghemng the of Roentgenologv last June, p. 360, says bone, Putti has used since 1917 an m- the true pathology of pyelitis of preg- strument which he calls the osteotone nancy consists mainly of dilatation of and which he described then m his arti- the renal pelvis and dilatation and kink- cle on ti^action by double skele al trans- ing of the ureter. He believes the lesser fi^^O". This osteotone is capable of pro- and medium grades of dilatation will en- Cueing a constant, gradual, and calcula- tirely recover, but the more severe ble amount of traction or extension of grades with atony of the pelvic muscula- ^'^^ bones. ture only partially recover under treat- It is necessary to know something ment. The colon bacillus is usually the about the elasticity of the contracted infecting organism, but others may oc- soft tissues, especially the muscles, casionally be primay or engrafted on the nerves, and fascia, in order to judge the colon infection. He lavs great stress amount of lengthening obtainable, upon the importance of early diagnosis The author has carried out extensive and treatment to prevent serious, if not experiments on rabbits in order to study irreparable, damage to the kidney. He the amount of lengthening of these tis- advocates pelvic lavage and drainage sues obtained Dy certain degrees of trac- and emphasizes the fact that these are tion forces. From his experiments, not dangerous. which were carried out under strict dynamometric control, he finds that it is possible to lengthen the normal limb by Orthopaedics Alonzo Myers, M. D., Dept. Editor direct traction upon the skeleton. Re- garding the elasticity or the amount of lengthening obtainable by certain force, the different tissues act differently Experimental Lengthening of the Limbs, among themselves, and there is also a (O. Nuzzi. Chir. Org. Mov., Vol. 6, No. 1, 1922.) difference between the living and the The division of bone for the purpose dead animal as well as a difference be- of operative lengthening may be accom- tween the lengthening obtainable in one plished by oblique osteotomy, by sitting and that obtainable in several sit- Z-shaped osteotomy of Vulpius, by the tings. He finds that in living elastic tis- U-shaped osteotomy of Fassett, but the sue, there is normally a certain unused best method is considered that of Putti, power of elasticity which can be made who divides the bone in Z fashion, incis- use of in operative lengthening of the ing the periosteum in the same manner, extremity. The lengthening has to be only with the short branches of the Z tolerated if carried out in repeated sit- cut in the opposite direction. The long:- tings. In regard to the vaginal fascia, August, 1922 EDIIOKIAL 441 the author finds that section of the fas- observation car which served as an au- cia increased the amount of lengthening ditorium for our "stunts." It was such possible. The force required for a cer- a convenience to have the men's com- tain amount of lengthening after sec- modius washrooms and "smokers" for tioning the fascia decreases to about aur exclusive use, though we did not one-fourth of the force required with the use the latter for the purposes intende:!. fascia intact. It therefore seems that We had an introduction to every one in the deep aponeurosis of the thigh ab- the form of a neat little booklet giving sorbs about three-fourths of the weight the entire schedule and the names and necessary to produce a certain amount space of everyone on board so we found of lengthening of the limb. our friends or made new ones very ^ ^ easily. There were about one hundred and seventy-five nurses on board. Every- thing was arranged for our comfort, even to serving afternoon tea. We were entertained en route bv an Nursing- r, o +u X- mipromptu orchestra consistmg of Dear Southern Nurses: — , , , , , ,,. * i i t? . „ , , . . combs and aukelele. Miss Adah Hersh- All the way to the convention in g,. ^^^^^ "community song leader." Seattle I was hoping for a large delega- y^^^^ t^^ t^^i^ stopped, we gave the tion from the South, and returning I ^^^^^.^^ a„ impromptu concert. Miss was constantly thinking of those who Marv Wheeler, Superintendent of were not able to go and wondering how Curses of Cooke Countv Hospital Train- I could write a letter which would give ing School, Chicago, was mistress of cer- any idea at all of how wonderful it was emonies ,nnd officiated as Bishop at a and compensate in a very small measure mock weddino- for not having been able to go. I'm At St. Paul" the local nurses met the afraid I can't do it but I want you to train and entertained us in true "Shrine" know I tried. gtyle. They presented us with souve- Though Virginia, our tair flower of nj^s of several kinds, all made in St. the South, has been transferred to the Paul and bearing an invitation to come Washington division, I .still feel it be- to St. Paul, "Eventually— why not in longs to us, so I am including you all in 1924?" As a climax of their hospi- tnis letter. To each of you, I bid God talitv, miles after we had left them, speed. I shall remain interested in all we were all eating Polar Ice Cream phases of your Red Cross work. Com- cakes (similar to Eskimo pie) and maca- mittees. Instruction, Public Health, roons. Territorial boundaries may limit our We'sped through the great grain fields work but heart interests do not recog- of the Dakotas and Montana and on nize them, and so to me Virginia nurses priday morning reached Glacier Park, must ever be included in the Southern j could only spend one day in the Park ^'^''^'''^"- because I had to be at the Board meet- I was not able to travel to Seattle with ings on Saturday, but into it I crowd- the Southern nurses. I am v-ery sorry ed sights on which my memory can to have missed the privilege of being feast the rest of my life, but just to with them. A family reunion in Wis- make such I got some fine snap shots, consin was responsible for my starting I wish you could all see them. When earlier. For the first time in twenty- you do come to the Division Office ask eight years all my immediate family me to show them to you. were together in one place- You will all Whether it was because of the West- forgive me for not getting off with the ern air, or the wonderful scenery or Southern delegations, won't you? the congenial company — or all throe However, in Chicago I joined the combined, I reached Seattle rested rath- "Nurses' Special," seven Pullmnn cars, er than weary. Mrs. McCanne, a dear two diners, a baggage car, and a great friend, (some of you may remember she 442 SOUTHERN MEDICINE AND SURGERY August, 1922 was one of our staff during the war) en- The rafters fairly rang! tertained me in her home which gave / This college spirit and youth per- me an opportunity to see much of the meated the entire convention, but did city, and have several wonderful auto- not in any way prevent the able dis- mobiles rides and a wonderful trip over cussions and wise deliberations and the ^ Cascade Mountains and to Mt. scholarly papers that have character- Ranier. ized our meetings- Dr. Palmer Lucas, The Y. W. C. A., where headquarters Dr. Olin Beard, Dr. Caroline Hedges and for the Convention was established, is other eminent speakers added inspira- a wonderful building. On the opening tion, counsel and instruction to the day every nurse was given a rose as she earnest efforts of our nurse members, registered. There were wonderful roses You will all hear of the papers in almost every garden— whole hedges through the columns of the Journal but of them— and the convention hall was j ^m afraid no one would tell you how a bower of roses the entire time. wonderful Miss Noyes looked in her From the beginning to the end of that beige colored hat with contrasting very full week we were impressed with brown and pongee colored gown and the changes that have come about in two-toned strap pumps, or her wonder- Nursmg Education in recent years and f^j black lace evening gown or Miss in the nurses themselves. It was very pox, in her light blue slip over sweater apparent that the old type training ^nd white silk skirt, hat, shoes, etc. She school, where the nurses served an ap- lo^kgd jjke the typical college girl of prenticeship, is passing and soon will the magazine cover. be as out of date as hoopskirts. The „ , 04. t. i i ur u- 4. -r* -, 1 J! -ill • Boston, St. Paul, and Washington, D. schools of nursing today are becoming ^ ,, u^ +i, 4-- f -iknA -, 1 , ^ "^ . . 1 C, all sought the convention for 1924. schools, where nurses are not required 04- n 1 • 4. 1 tit 4. 4. i •4-1, , J J 4.1 4. 1 4.1 4. St. Paul, m truly Western style, with to do over and over the tasks that can . ■, , , • ttt- u- 4. 1 -1 4¥-T 4- J •4-T„ 11 J souvenirs and loud voices — Washington, be easily affiliated with colleges and , ^ u u i, • 1 .;. J ,, ^ 4. 1 • because Congress should be impressed universities and the nurses ate taking .., , j ,• 4^ ,-, . 4.-4.- j?4.i4. m with our members and importance — on the characteristics of students. Ten t^ 4. .4. •4.u j? 4.1, 1,4. I, j • 1 V 1 4. 1 I TTT 1 J Detroit, with forethought, had circu- years have brought changes! We older , ' ,, , . we left home and ,. . r~n • • -ir>-ir» idl lAcU US ail UciOI C VVc lei L IlUlIlC ctllLl nurses m convention m Chicago m 1912 « „ , ., 1 ., 4.- , ■, would have been shocked to have par- fo"owed it up by floating banners and ticipated in class yells in the solemn f^gs-Boston m true New England sessions of the A. N. A. At Seattle it fashion wore bandages by blue and si 1- .,,.,,. , „ ,, ver ribbon. Come to Boston m 1924, was quite the thing and some 01 the j j- , i n u 4.-^? 1 1 ,j J4.U 4-j- -£1^4- and displayed an equally beautiful large older ones, and the most dignified too, , £ ■^^ u • li, • -4. 4-- % 11 d the 1 d f banner of silk bearing the invitation of ^ ^ " ., ■ . . the Massachusetts State Association. Community and group singing . brought us close together under the Detroit won, proving the adage. The wonderful leadership of the Community early bird catches the worm." Detroit Song Leader of Seattle. Of course, we is already a fireside name to most Southern nurses sang "Dixie" and we nurse. Let's start a "home run" for sang it for all of you who could not ^^^ Lizzies." come. We had a Southern dinner and ,_. . ,' -r^, , . , j- ttt- about fifty nurses were present and all ^'^^ ^dda Eldridge of Wisconsin was of our states represented. I was in- elected the new president of the Ameri- deed proud of you all. can Nurses Association- Miss Laura Miss Brougher, of Mississippi, gave Logan of Cincinnati was elected presi- us a yell and led it. dent of the League of Nursing Educa- ''Hip, hip hoo ! Howdy do. ^.^^^ ^^^^ ^^^ ^^^^ ^^^^ Elizabeth Fox We are all Southern Nurses. Who are , 4. , ■■, x ^ ^1 xt 4.- i ^ was re-elected president ot the National We are for progress! We are for pep! Organization for Public Health Nursing. Dixie, Dixie, pep! pep! pep!" Conventions are milestones of prog- August, 1922 EDITORIAL 443 ress and now we face the next stretch W. Long, Greensboro, N. C. of endeavor and accomplishment. What Venereal Disease Nursing — Ann shall be our part in it? Shall we not Doyle, R. N., U. S. Public Health endeavor to improve ourselves person- Service. ally and professionally, through our Maternity and Infant Welfare— Ann opportunities to learn from people, our Stevens, Field Director, American journals, advance study, etc. Let us Hygiene Asociation. strive for better organization, the great- "The Nurses' Part in the U. S. Vet- er assumption of responsibility for erans' Bureau"— Katherine DeVine, R- health by our Boards of Directors, our N., Chief Nurse-Veterans' Bureau, At- Nursing Committees, our public of- lanta, Ga. fiicals. Let us not take or appear to take The States Responsibility for Her the greater responsibility resting upon mental Defectives," — Mrs. Clarence the physicians or the people. Ours to A Johnson, Commissioner State Board interpret the procedures reaching and of Charities and Public Welfare, maintaining health and to translate "Nursing Ethics" — Jane Van De- them into comfort, care of the sick and Vrede, R. N., Director-Nursing Service pleasurable habits of keeping well. To American Red Cross, Atlanta, Ga. that task we can employ all our efforts. "The Need, Workings and Results of With best wishes for success and the Clinic" — Dr. G. M. Cooper, Raleigh, happiness, I am, N. C. Cordially yours, ^ ^ Jane Van DeVrede. News Items The North Carolina State Nurses Association will hold its annual meet- ing September 5-6-7 at Greensboro, ,^^_ ^^^^ Alexander, of Knoxville, N. C, Nurses Lets Go -also let s Tennessee, recently spent a day with make the meetmg go This must be ^^.^^^^ .^ Richmond, Virginia, and will be a wonderful get together meeting of North Carolina nurses- The Dr. Stephen Harnsberger, of Warren- association has questions of policy to ton, Virginia, has lately been in Rich- discuss and decide and in this time of mond on professional business, co-operative activity it takes full co- ^,.„.^^ ^ ^^.^^ superintendent operaton to make our influence fel and Elizabeth's Hospital, Washington, to accomplish for the nurses and the .^ j^j^j^^^^^ .^ ^^,^^^1^^. people they serve the greatest good. Every nurse in the State of North Caro- "°"- lina owes it to herself to arrange now Dr. J. Shelton Horsley, of Richmond, to attend this meeting. has just spent a week with friends in Come to co-operate. Among the Albemarle County- many good things on the program the ^ ,. ^ . -kt a j; n- u ^ following are mentioned: Dr. McGu.re Newton of Richmoncl Address of Welcome-By Member of ^as spent a brief vacation m Atlantic the Guilford County Medical Society, ^^^y- Administration and Education for the Dr. P. G. Hamlin, formerly a member Training Schools— Agnes Deans, R. N., of the medical staff of the Eastern State Washington University, St. Louis, Mo. Hospital at Williamsburg, Virginia, is The Value of Trained Women for doing post graduate work in the North. Tuberculosis Work— Dr. L. B. McBray- ^ , ^ „ , . , ^ . er, Sanitorium, N. C. Dr. S. S. Gale, of Roanoke has lately Mental and Nervous Cases and Their been spending a few weeks at the Mayo Care— Dr. Louis Beall, Black Mountain, Clinic. N- C. August Harper's has another chap'.er Illustrated Lecture on Cancer— Dr. J. from the autobiography of Mark Twain. SOUTIIKRN MEDICINE AND SUKGERY August, 1922 Table of Contents for August, 1922 Original Communications. Focal Infection the Cause of Much Mental Disturbance, by Henry A. Cotton, M.D.-- SST) Diagnostic Surveys by Diagnostic Commis- sions for Asylum Populations, by Chas. A. L. Reed, M.D. 39f) The Value of Psychoanalysis to the General Practitioner, by Louis E. Bisch, M.D 402 Behavior of the Feehle-Minded— The Lay- man's Ignorance of Their Anti-Social and Criminal Tendencies, by Jas. K. Hall. M.D. 411 Preventive and Prophylactic Practice of Orthopaedic Surgery, by Alonzo Myers, M.D. 413 Early Diagnosis of Breast Tumors, by Jas. W. Gibbon, M.D. 417 Vomiting, by George M. Niles, M.D 421 A Word About Diagnosis, willi Illustrative Cases, Especially the Report of a Case of Metastatic Abscess from Intestinal In- toxication, by Stephen Harnsberger, M.D. 424 State Institutions and Medical Education, by M. L. Townsend. M.D 42'! Editorials. Give Abnormals a Fair Chance 4:!:'. Fadism in Medicine 4;;4 Psychology in Tuberculosis 435 Department Editors. Surgery. A. E. Baker. M.D 43r. Mental and Nervous, Jas. K. Hall, M.D.__ 43S Urology, A. J. Crowell, M.D .-_- 44(i Orthopaedics, Alonzo Myers. M.D 44(i Nursing 441 News Items 443 I The committee looking to the estab- lishment of a full four year medical course in the University of North Caro- lina consists of Edgar W. Pharr, Char- lotte, N. C; J. L. DeLaney, Charlotte, N. C; W. N. Everett, Rockingham, N. C; H. P. Grier, Statesville, N. C. ; Dr. H. W. Chase, Chapel Hill, N. C; Dr. I. H. Manning, Chapel Hill, N. C. ; Dr. W. deB. MacNider, Chapel Hill, K C. Dr. William deB. MacNider, of the faculty of the department of medicine of the University of North Carolina, re- cently spent a day with friends in Rich- mond. Dr. N. Thomas Ennett, with hi.' fam- ily, IS spending a few weeks at his lodgt near Morehead City, North Carolina. Dr. Miles J. Walker, of York, South Carolina, died after chronic ill health at a hospital in Richmond, Virginia, on July 11. Dr. Walker was 65 years of age, a graduate in medicine from the Louisville Medical College in the class of 1879, and for years he had been ac- tive in general practice and in the medi- cal organizations of his native state. Dr. R. D. McMillan, formerly of Red Springs, North Carolina, is now doing an extensive general practice in Hinton, West Virginia- Dr. Philip Taylor, of Richmond, Vir- ginia, died at his home in that city on August 1, in the seventy-second year of his age. He was a native of New York City, a .graduate in medicine of the Col- lege of Physicians and Surgeons of that city in the class of 1876, and for many vears one of the leading specialists of Richmond in diseases of the eye, eai'. nose and throat. Several years ago he retired from active practice. The annual picnic of the Roanoke Academy of Medicine and Surgery has just been held at Salem, Virginia. In a hotly contested baseball game between the Roanoke doctors and lawyers, the score of 13 to 5 was in favor of the medical men. The proceeds of the game went to the community chest. Dr. W. T. Carstarphen, formerly a member of the staff of the medical de- partment of Wake Forest College, is now doing general practice in Plains- field, New Jersey. Dr. Arthur S. Pendleton, formerly a member of the medical staff of the State Hospital, Raleigh, North Carolina, is now a Lieutenant-Colonel in the Medical Corps of the United States Army, and is stationed at Fort William McKinley, Philippine Lslands. His family is with him. Southern Medicine and Surgery Vol. LXXX(V CHARLOTTE, N. C, SEPTEMBER, 1922 No. 9 not to walk on. Mr. Kelly would reas- RELATION OF THE COUNTY MEDI- on, doubtless, that General Gorges had PAT ^f^r^VTY to TOCAT nothing to do with the health eondi- CAL SOC.1E1Y lO LOCAL ^j^^g jj^ Panama, but that since 1881 HEALTH WORK.* when the French were compelled to re- linquish the project on account of ma- J. T. .T. Battle, M. D., laria and by 1904 man had become by Greensboro, N. C. evolution immune to malaria. It would be almost amusing to hear Mr. Kelly When thi.« subject was submitted to call for a doctor if he were to have a me, it was taken for granted that it was j-e^l good case of cramp colic, to be viewed from two angles-first. ^j^. j^gjjy,^ ^^.^^ ^^ ^jjj ^^^^ ^^ j,^_ IS the present relation entirely satisfac- ^^^^^^^ ^^,.^^ ^^^ American people and tory? Second, if not what should it be? ^^^^^ ^^.jjj continue to buy patent medi- A very superficial study develops the ci,-,e^ ^^ the cost of millions of dollars impression, if not the fact, that there annually, and send for doctors whenever now exists between the well or healthy t^ey are sick, even the Christian scien- people of every community and the reg- tists and the other drugless practition- ular medical profession a difference or gi-g ^j^. Kelly's effusion is a straw in- rather an indifference which amounts to cheating in some degree public opinion an estrangement as to their professional Qf ^^e profession. life; however, this is obliterated in ^^^^ -^ ^^ ^1^^^^ f^^ this state of times of sickness. ^-^^ ^ j^^^ the examining boards too In justification of this opinion, be- j^^ and allow incompetents to pass sides the every day observation of the them? Are the doctors sufficiently situation, is an article by Mr. Fred C. qualified to do first class work? In an- Keily in the April number of the Cos- ^^^g,, to these questions, it must be ad- mopolitan in which he proves to his j^itted that the average physician is entire satisfaction that "the only fair too often negligent in diagnosis, if so conclusion taking the proposition by and j^jg treatment is necessarily guess work, large, seems to be that doctors have ^^jg condition has not only permitted had little influence on mankind one way y^^^ actually paved the way for one or or the other; the indications are that ^^^^ cults to spring up overnight who we are just about where we would be ^^e wielding some influence, yet its ad- if there were no practicing physicians." herents are not trained in a single one The Editor in commenting upon this ^f the fundamental branches of the contribution says that Mr. Kelly makes practice of Medicine, two plus two equal five when he wishes to do so. Mr Kelly's deduction as to What Should Be the Relation? the doctors is in keeping with his arith- When the great Physician was upon metic. He attributes the present im- the earth, his key word and great work provement of the general welfare of was "service." He not only taught it the people to evolution, and he proves but practiced it. When the Jew was the theory of evolution by the shape of on his way to Jericho, he very probably a man's foot, saving it was made to fit had gone out of his way so as to avoid around a tree for climbing purposes and going through Samaria m order not to become contaminated by coming m con- *Read bv title at tbe Winston-Salem meet- t^ct with the half breed and despised Aprii°^25* 27, 1?2? *^^'°""^ ^^^^'^^ ^''''^*^' Samaritans; when overtaken and over- 446 SOUTHERN MEDICINE AND SURGERY September, 1922 come by the robbers and left for dead, it was a Samaritan, although knowing _ himself to be despised by this unfortu- THE RELATION OF GENERAL nate man while in health, who rendered PRACTIONER TO VENEREAL every assistance that he needed to re- store him to health. DISEASES.* The Guilford County Medical Society is now going on record and arrange- Presented by ments are now well underway to follow Dr. James A. Keiger, though afar off, the example of the Greensboro, N. C. great Physician and give service to every man, woman and child in the For the past five years we have heard County, and County lines may be wiped and read much about the venereal dis- away unless our neighboring County So- eases. We have been told that gon- cieties claim that privilege for them- orrhea and syphilis are more prevalent selves in their own Counties. than any other infectious disease, ex- We are determined that the Sama- cept measles ; that probably 50 per cent ritan shall not stand alone as the of the abdominal operations on women neighbor to the sick, afflicted or needy, result from gonococal infection usually Our plan is to work up interest at vari- contracted innocently ; that a large per- ous strategic points in the County by centage of the blindness in children is newspaper articles, pamphlets on special traceable to infected mothers: that subjects, lectures by the County physi- still-births and early deaths to syphilis, cian, pastors, through the day schools, These facts, coupled with the loss in Sunday Schools, Churches, moving pic- physical power on the part of those who tures, etc., and on certain days a free are infected, place the venereal diseases examination will be offered and every in the front rank of medical problems, one in the community will be urged to Considering the wide-spread preva- take advan^iige of the opportunity ; ^^^^^^ ^f ^hese infections, I believe that when a diagnosis is made the applicant ,. , ^;„K„f „^ „,^n oa .„ , J^ 1 ^ ^ ■ 1^-1 everv medical man, specialist, as well as will be referred to his or her family ' . . . .. „ • ^ i. physicia.v If complex cases difficult to general practitioner, is vitally interest- diagnose should be brought up, then an- ed. For there is no field of medicine that other appointment will be made and a does not at some time or other encoun- specialist will be brought in and the ter a svphilitic or gonococcal infected case continued until a satisfactory diag- p^tient.^ If then the various specialists nosis is arrived at, the case will then , .,. ,, j 4. 4-i,„ , . J . u • • 4? u- ,,v, meet with these cases, does not the gen- be referred to a physician of his own choosing. Up to this point, no fee has eral practitioner meet with them more been charged. This work will be in so, since he is a combination of them co-operation with the State Board of all? ^^^J^^: . , . J r .u The analogy is not perfect, but I be- The time has now arrived for the pro- ,. .,^11 ^v, 1 fession to educate the lay mind out of ^^^ve we might look upon the general the superstitution which is well nigh medical man as the clearing station for universal, and mysticism which is so all the casualties. For, to him the wife extensively believed is essential to the comes when she has some "female" or practice of medicine. bladder trouble; to him the mother When we shall have taken all the ^ ^^^ ^^.j^^^^^ ^^^^ ^^^^ ^^^ „^t people into our confidence and they are ^ , , , . ^1 v, made to know that we are working for doing well ; and, to him the boy or young their good, then t^e relation of the man reluctantly reports when he rea- County Society to local health work will / -• J +1,^ *Read at the W nston-Salem Meeting of assume greater proportions, and the t^^^^^^orth Carolina Medical Society, April doctor will be held in higher esteem. 27, 1922. September, 1922 ORIGINAL COMMUNICATIONS 447 lizes that he has been indiscreet. Thus -. 3 see that the physician has the first RELATION OF PUBLIC SCHOOLS opportunity to detect a gonorrheal or _ syphilitic infection in the wife, father, TO THE HEALTH DEPARTMENT.* mother, or children. Supt. .S. B. Underwood, Having made the diagnosis, and there Raleigh, N. c. is no reason why he cannot, for the laboratory of the State Health Depart- I am glad of this opportunity to ex- ment is always ready to aid, he must press publicly in some measure the ap- (lecide which cases he can and will prop- pfeciation which I am sure all the craly treat, and which he will refer. I school men of the state feel for the work use the term "properly" advisedly. For of the health agencies that are doing so persons infected with gonorrhea or much to put North Carolina forward, syphilis are seriously ill and deserve to From state health officer down, we feel be treated with the same care and skill that we are greatly indebted to you and that is given to the typhoid, pneumonia are proud to work alongside you. In or diphetheria patient. analyzing the Y"emarkable progress made To discuss in detail any of the various i" Public education in North Carolina plans of treatment would take entirely i" recent years. I am sure that your too much time, so I shall make only a ^'o^k is responsible for a great deal of few general remarks, relative thereto: the improvement that has come about first, the general practitioner must, at "^ ^^^ '^^°°' ^^^"^• least, treat the acute cases, for there are "^^^'^ '''°" ^^,1! v^ ^ community for- . ,. , . , . ward along health Imes, j^ou have made not specialists enough in the state to -^ ^^ ^^^^ ^^ ^^^-^^ pl^^^ -^ ^^-^^ ^^ handle them if they are all referred develop wholesome educational senti- But let me add that, unless he is willing ment ; conversely, when educational sen- to examine his patients, he should let timent runs high, it is easier to do ef- them go to the druggist and quack as fective health work. I am sure that ,, , , J • • i-v, 4. you will find the largest percentage of they have been doing in the past; sec- ;f , ., • .• . +1, ^^ .. ; „ , , ^ . ' , typhoid vaccination and the smallest ond, refer the chronic cases to the proportion of preventable diseases in specialist and do not tell them that they the communities that have the best are incurable ; third, do not be in a hurry schools and have had them for the long- to treat ulcerations on the genitalia with est time. In my experience, I have in- caustics, but rather consider all such variably found that my school work was ,.,.,. .., J i-u easiest in those communities where the cases as syphilitic until proved other- ^^^^^^ department was flourishing most wise by the microscope or other labora- effectively tory tests ; fourth, do not tell a syphil- j^ ^^^ ^eg^^ ^^y good fortune for the itic that three or six "shots" are suf- past eight years, the first seven as a ficient, for, in the light of our knowledge. County Superintendent and the last in we do not think it is, in fact, know that city work, to work in close conjunction it is not, in the vast majority of cases, and co-operation with an organized and Tiri, ..\u • ^u 1 ^- 4^ ^-u efficient department of public health. What, then is the relation of the gen- J" c^^^ ^^ P ^^^ ^^p^^tment has been eral practitioners to venereal diseases? ^^ strongest ally, its directing board I think it can be answered by saying ^ close personal and professional friend that it is the same as that towards — a sort of companion in arms. I am tuberculosis, cancer, malaria, etc. And convinced beyond the possibility of the solution rests on cooperation of all doubt that it has made my work incal- ,., .. ^, ■ , . rp . 4. culably easier; I should like to think medical men giving their best efforts to '^"^'^"'^ diagnose early and then treat with skill *Read before the Winston-Salem Meeting of the North Carolina Medical Society, April and care. ^5.27, 1922. 448 SOUTHERN MEniCINE AND SURGERY September, 1922 that I had made some contribution to the success of its task. A county or city superintendent of schools, a teacher or principal, or anyone connected with the school system, who is unwilling to go out of his way, if neces- sary, to render assistance to the health department is very much in his own light. We are working for a common end. Why not join hands and work to- gether for its attainment? The school forces have, or certainly should have, the confidence of the com- munity. They should use this confi- dence to pave the way for the general and special work of the health depart- ment. The health officer or any mem- ber of his staff should have access to any school at any time that there is a piece of health work to be done. And the school should not hesitate to use its influence to create favorable sentiment for the health department. In fact the health department should be regarded as a part of the educational organiza- tion. The county or city superintendent should make it a point to have the health officer appear before the teachers and school committeemen to outline his poli- cies and enlist their support. The child- ren should be taught the workings of the department as a vital part of the county government and to be made fa- miliar with its phases and its methods. The health officer should be invited to the schools and be given an opportunity to get acquainted with parents and children. Literature of the department should be distributed in the homes and studied in the schools. In this way sen- timent can be created for the work of the department. Not only should this educational work be done, but the department's authority in health matters should be clearly and definitely set forth and fully acknowl- edged. I have on more than one occa- sion referred matters to the health de- partment that I could easily have hand- led myself because I wanted teachers or public to get the habit of consulting the health officer. It goes without saying, I hope, that the department's regulations should be carried out to the letter and every re- nnirement scrupulously complied with — and complied with promptly and with the utmost cheerfulness. Not only should the school teachers and superin- tendent do what is required, but they should look for and search out oppor- tunities for the health department to function. There should be no suspicions, no jealousies, no bickering no strife — but a full and free working together for the common good. We are all anxious to have a stronger, healthier, happier citi- zenship. Why not pool our resources. Let every school be an outpost of the health department, ready and anxious to aid in the conservation and enrich- ment of human life. MILK INSPECTION FROM A PRACTICAL VIEWPOINT.* Mr. J. H. Heald, Winston-Salem, N. C. In endeavoring to present to you my ideas on the subject of "Milk Inspection from a Practical Viewpoint," I realize that I may depart somewhat from sev- eral points which many men consider essention to the production of a (rood grade of milk. I confess that fifteen years ago, my ideas were not what they are now. In those days, I was inclined to think that all milk of a lesser grade than "Certified," produced under the ideal conditions which surround the pro- ductions of "Certified Milk," was in a class with bichloride or cyanide, let, today, we have in Winston-Salem no "Certified Milk," but we do have what I consider to be a very high grade, low count, reasonably safe milk supply. Our baby death rate from colitis and other intestinal diarrheas is constantly grow- ing less— due partly at least to our im- proved milk supply. *Read before the meeting of the North Carolina Medical Society held m Winston- Salem, April 25-27, 1922. September, 1922 ORIGINAL COMMUNICATIONS 449 It is my opinion that we health pco- in their product that they want their pie have, in many instances, by arbi- outfit to be in keeping with this product, trary insistance upon non-essential re- Next comes METHODS, and under quirements, discouraged the production this head we require roughly as follows: of perfectly good milk, antagonized the (1) Brushing the cow and washing farmers, and made many unnecessary the bag and teats just before milking, enemies. (2) Clean, dry hands. We are trying in our work here, to (3) Early removal of milk from the boil down our requirements to those that stable to the milk house, we consider have an actual influence on (4) Prompt cooling and aeration, the quality of our milk. As a result we (5) Immediate bottling, have more than doubled our prod'.iC'3rs, (6) Adequate refrigeration, yet we believe each is equipped with the (7) Thorough cleaning and scalding esesntial factors for producing clean of all pails, cans, strainers, bottles, etc. milk. In addition we feel we ha/e that In addition to equipment and methods very valuable factor — the goodv/ill and as described above, we require the an- co-operation of our men. nual tuberculin testing of all cows sup- What are our minimum requirements? plying milk, cream or buttermilk to the (1.) A lean-to or a portion of the city. At present the County is doing stable partitioned off and equipped with this work free of charge — a method of a cement floor and gutter to which the which we heartily approve, cows may be brought for milking. I have long been of the opinion that (2.) A milk house separate and apart the eradication of tuberculosis in cattle from the kitchen to which milk may be should be considered an economic dairy brought for cooling, bottling and stor- problem rather than a health depart- ing. This milk house must also have a ment problem. It has undoubtedly been well-drained cement floor, and is gener- on account of the indifference of the cat- ally built in two rooms — one for the tie industry toward cleaning up its herds dirty work, the other for handling the that health departments have been milk itself. It is, of course, well screen- forced to take action. This method ed during the fly sea.son and every ef- touches only those cows that supply a fort is used to exclude flies. particular city and leaves untested by (3) Small top milk pails are required, far the larger majority of the cows in (4) A Champion or other satisfactory that county. For example, until Forsyth type of cooler and aerator ! County Commissioners took up this (5) A tank of 25 to 40 gallons capacity work, we tested only 2,500 out of the under which a fire may be built for pro- probable 10,000 cows in the county, viding hot water for washing and scald- In connection with pasteurized milk ing. which constitutes over half of our total (6) A refrigerator of sufficient size supply, we require the usual standards to hold an ample supply of ice. of heating to 142 degrees to 145 degrees Roughly speaking, these are our re- for 30 minutes, immediate cooling to quirements. Of course, some of the men below 50 degrees and storage below 50 fix up much more elaborately than oth- degrees until delivery. No exception is ers, and we always assure them that any made a? to T. B. testing, extra flourishes do not hurt our feelings Samples are taken ait least^ twice in the slightest. I much prefer to have montnly, examined for fat, solids speci- them spend this extra money on their fie gravity, and bacteria per c. c. At the own initiative rather than under com- end of each month, an average of all pulsion; and it is surprising how many samples for each man is determined, men will spend more than is absolutely listed, and a copy of all results mailed necessary if they feel that they are do- to each man. This stimulates interest ing so of their own free will. Then and competition. We do not publish re- there are others who, when they begin suits in the paper, but any man's rating to get good results, take such a pride is freely given to an inquirer. An aver- 450 SOUTHERN MEDICINE AND SURGERY September, 1922 age grade is figured on a six months Another way to obtain the confidence basis, and a new man must have at of your men is to require exactly the least three months of laboratory analy- same minimum standards from one as sis before we will give him a grade, from another. Don't allow any special It takes me at least that long to be sat- privileges or concessions to anybody, isfied as to what a man can and will do. It's a little hard at first to say "NO," Because of the small number of dai- but soon they will not expect a "YES," ries engaged in retailing milk (27 in and will be prepared to meet your re- all) I do not find it necessary to depend quirements. Special privileges are the very strongly on the score card of the hardest things in the world to explain Dairy Division. The score card is un- to the other fellow, doubtedly of great help to a field inspec- In closing let me say that while I tor who must supervise and be able to recognize that perfection should be our recall the details of a large number of ideal, yet the fact remains that by far dairies, but for the number of dairies the larger majority of our farmers are supplying a community of this size, I not, and probably never will be, in a find it of little assistance. Then, again, position to realize this ideal. It is the as our knowledge of those factors which practical milk inspector's problem today actually influence the quality of milk to get good, pure, safe milk from the increases, we find many apparent incon- dairies of today, and with the minimum sistencies between laboratory results amount of equipment and expense. He and dairy conditions as shown up by must help the farmer to preserve what the score card, which are sometimes em- little profit he is making, and at the barrassing to explain. I refer to such same time the health of the consumer, items as number of square feet of light- That we can procure a high quality ing surface, number cubic feet of air of ^ilk that compares very favorably space per cow, number of feet between ^ith the output of our most elaborate manure pile and cow barn, and several dairies, is being proven to my complete other points. satisfaction'. How do we accomplish Another point which I wash to em- this? By installing the minimum phasize as essential to successful in- amount of essential equipment, and spection is the securing of goodwill and bearing down hard on methods, trust of the dairymen. I make it a As a result of our system in Win- strong point to convince my men that ston-Salem the following figures are of the laboratory and its findings are of as interest : much benefit to them as to the customer. From January to July 1920 there I always try to find the explanation of ^ere 0 producers who averaged under an abnormal fat test or a high bacteria io,000 per c. c. count, by asking questions and encour- ^^^^ j^jy ^^ January 1920 there aging frank answers, even tho, they ^^^ ^ producer who averaged under may convict that person of some easily ^q qqq p^^. ^ ^ avoidable carelessness. When a man has '^^^^ j^^;^^^ to July 1921 there enough confidence m my fairness to fur- ^^^^^ ^ producers who averaged under nish his own answer to his own ques- ^ tion of "Why did I have that high count ^^;^^" P^; ^- \ last week," I feel that he has the right From July to January 1921 there conception of the relationship that were 8 producers who averaged under should exist between himself and the 10-000 per c. c. inspector. An explained mistake gen- Our average yearly bacteria counts V. •„ ^ \ • rs „-„„ii„ of a 1 milk were as follows: erally will not occur twice. Occasionally 254 000 I have one who declares that nothing ^^^^ rrr'rmiIII~---112!oOO out of the ordinary occurred to cause 1919 "_~~"m 99,600 the trouble, but I am glad to say such 1920 45,600 answers are getting rarer. 1921 29,300 September, I922 ORIGINAL COMMUNICATIONS 451 By laying special stress this year welfare officer as outlined in the statute upon iceing both at the dairy and on the which is but a suggestion of the mani- delivery trucks we hope to excel our fold duties he is called on to perform : ]921 record. (a) To have, under the control of It is my suggestion to those of you the county commissioners the care and who are, or may later become, interested supervision of the poor, and to admin- in milk inspection work to see that your ister the poor funds, inspectors get down to brass tacks, that (b) Under the direction of the state they ask only what is necessary, that board, to look after and keep up with they eliminate everything that unneces- the condition of persons discharged sarily irritates dairymen, that they gain from hospitals for the insane and from the confidence and work with him using other state institutions, the police court only as a last result. (^) To have oversight of prisoners in the county on parole from peniten- tiaries, reformatories, and all parole PUBLIC HEALTH AND PUBLIC prisoners in the county. WFTFARF roRRFT ATFn TN ^^^ '^° ^^''^ oversight of delinquent WELFARE CORRELATED IN ^^^ dependent children, and especially COUNTY WORK.* those on parole or probation. (e) To have oversight of all prisoners Samuel E. Leonard, in the county on probation. Superintendent of Public Welfare, ^^^ ^^ promote wholesome recreation Wilson County. .^ ^^^ county and to enforce such laws Speaking for the welfare department ^s regulate commercial amusement, in general I wish to thank you, the is) Under the direction of the state Public Health Association, for your board, to have oversight over dependent courtesy in your recognition of Public children placed in the county by the Welfare and for this place on your state board. program. Public Welfare in North Car- (h) To assist the state board in clina is less than three years old while finding employment for the unemployed. Public Health is many years its senior. (i) To investigate into the cause of Social legislation of the present day, distress, under the direction of the though far behind the needs of the time, state board, and to make such other in- is the outgrowth of other movements vestigations in the interest of social on social work such as yours. It was welfare as the state board may direct, quite natural for Public Health to come Can you think of normal persons ap- first because life and death, sickness and plying to the county for $2.00 a month accident, are more impressive on the or for shelter in the county home? Are minds of the majority of our people people discharged from an insane hos- than the raising of social standards, pjtal normal, if so why should they be Public Welfare is not a spectacular j^gpt up with? Are paroled prisoners thing, does not cater to the big head- and delinquent and dependent children lines and hence is harder to put across, normal? No, we are dealing with ab- But the health officers have been our normal folks and abnormal situations. champions and have done much to make These abnormalities are both mental the work a success. and physical. To diagnose the case we I wish just here to lay down this fun- need a double-barreled man, one who damental in social work: Public Wei- can see with two sets of eyes. We have fare deals with the abnormal, not the such men, one in this state, the psy- normal. Let me name the duties of the chiatrist, but they are far too few. But the psychiatrist is first of all an M. D. *Read before the North Carolina Public jjg mUSt be this for the physical and Arr!f^24.^'922:^''''"' Winston-Salem, N. C, ^^^ ^^^^^^ ^^^ ^^ ^j^gely connected. 452 SOUTHERN MEDICINE AND SURGERY September, 1922 Now the welfare officer is not a trained psychologist every time, but with his experience in handling situations, and his study, with the opportunity of call- ing in the state expert on special cases, he should be able to diagnose the men- tal situation. Now with the proper co- ordination, the welfare officer and the health officer should make the necessary combination to put over a successful social program in a county. I was interested in looking over the programs of the ninteen public health institutes being conducted in as many cities of the country by the United States Health Service cooperating with the State Boards of Health, one of which is this week being held in Spok- ane, Washington, 281 lectures, or more than one third of all the lectures given in these institutes are closely linked up with Public Welfare. There are such general subjects as child hygiene, men- tal hygiene, medical social work, pro- tective social work, and the delinquent. All these subjects under more specific headings are being discussed by the leading men in the medical profession. This means that men higher up have seen the vision and that Public Health men who like welfare men are public servants, and who, by virtue of their position must necessarily deal with so- cial problems, are being instructed along social lines. The welfare officer is absolutely dependent on the health officer, for he within himself cannot handle both phases of the social prob- lem. The health officer with the social training is a good combination within himself. He is in position to handle a few individual cases but the field is so large and the work so complex that the workers, both social and medical, must be materially increased if the work is to be adequately done. In order to see how entirely depend- ent the welfare officer is on the health officer and how the work overlaps let us see some of the general problems which must come up in every county where there is both a health officer and a welfare officer. A child is to be sent to an orphanage or the Children's Home Society. The health officer gives the examination. A prostitute woman is placed in the court by the welfare officer. The health officer takes a Wasserman, makes recommendations and possibly treats the woman in prison. Compulsory school attendance is in the hands of the welfare superintend- ent. Vaccinations, medical examina- tions and all health work are in the hands of the health officer. A bed ridden man is placed in the county home by the welfare officer. He is a patient of the health officer as long as he lives. The welfare officer has the oversight of prisoners in the county, yet when sickness comes along the health officer is called in. An insane person is confined awaiting transfer to the state institution. The health officer must examine the pa- tient both physically and mentally. A girl is committed to Samarcand or a boy to the Jackson Training School. The health officer must first pass upon the case. This list could be continued because as I have said all social problems are con- cerned with the physical and mental make-up of the case. To show some specific health prob- lems that have been handled by welfare officers I cite the following: All these counties except one have no whole time health officer. In Pasquotank county, the welfare superintendent, a capable woman, is taking a great deal of interest in the health of school children. She has been instrumental in getting a milk kitchen established for the undernourished children and more than a hundred child- ren of the poor class are given a pint of milk a day, the results being a two to five pound gain in each child during the first month. Rutherford county Superintendent of Welfare has put on a typhoid vaccina- tion campaign in co-operation with the State Department of Health and 500 people were vaccinated. A tonsil and adenoid clinic has been held and 75 children have been operated on, a dental clinic and 900 children had teeth filled, September, 1922 ORIGINAL COMMUNICATIONS 453 while 1,100 children were examined by But Public Health is more than that, the State Health Nurse. It is so much more that you, every one Way down in Dare county, the coun- of you, find yourselves working about ty of islands, the Superintendent of Pub- half your time on kinds of work that lie Instruction who is also welfare of- you cannot put on your "charge sheet." ficer, a woman by the way, has inter- Public welfare officers are working all ested the State Board of Health and the time on such work. Then too, there nurses have been sent to examine the has never been any price fixed on social f;chool children. A clinic is planned for work. But whether the community the early summer. knows it or not it is paying heavily In Haywood, a small mountain coun- every time it neglects its social needs, ty, the welfare officer has taken advan- The war has taught us many lessons tage of nature herself and has put in and I suppose we will be drawing on the a sanitary system of piping water from experience for years to come. We have the mountain sides to the .school houses heard a great deal about the physical where sanitary drinking fountains have unfitness of the men. But we have been installed. Dr. Cooper has operated heard less about the mental and nervous on 125 of his school children and 1,000 diseases which after all are the barom- have been treated with dental work, eter of the mental stability of a na- The welfare officer has held a five day tion. This is a national problem of mo- tuberculosis clinic and of the 81 exam- mentous importance and it receives only ined the doctor found 13 positive cases, scant consideration. There is only a There is no whole time health officer or very few medical schools in the country nurse in the county so that welfare which make a pretense of adequate in- officer has been instrumental in getting struction in neurology and psycharty. much done. We build State and National institutions Over in Rowan county we have a and lock up in them in excess of capacity woman who has done a big work for those who cannot live in society with crippled children. She has interested safety to themselves or others, but we outside agencies to the extent of hun- do not study the causes, nor do we dreds of dollars and has placed many strive to control and prevent what is "Tiny Tims" on their feet. suceptible of substantial control and pre- I mention these few cases, varied in vention. character, to show the interest the wel- But the psychiatrists and neurolo- fare officer has in the health of the gists,, although few in number, did a county. The same thing could be said big work with the army men in classifi- about the social work the health officers cation. Of the 69,394 men who were are doing. fully classified up to May 1, 1919, 63 per I have been interested in a compara- cent were clearly socialogical problems five way in the Public Health plan of while the remaining 37 per cent were having a standard of charge for service classified as medical, such as psychoses, rendered, representing the cost, by epilepsy, organic nervous diseases, and means of which a financial record may glandular disorders. But the 63 per be kept. I understand it was hard to cent, consisting of neurotics, drug and work out. If the dollars and cents alcohol addicts, psycopaths, and feeble- method in Public Health work has been minded, while being medical problems, hard to work out it is next to impossible are more. They are social problems that in Social Work. You men were original- cause concern in every community, ly trained for a certain job, that of diag- What to do with them is a question in nosing physical ills and applying reme- the mind of every social worker, every dies therefor. Most of you have done health officer, every judge, and all of- some practical work before going into ficers whether State or Federal. It is a this most altruistic work of keeping problem of health, yes, but it is more, communities well. You fixed a price for The morale of the country is lowered a specific job. Now you apply the price, by their presence. Doctors must car- 454 SOUTHERN MEDICINE AND SURGERY September, 1922. ry their part of the load and social work- are standing on the threshold of a new ers on the other hand have their part system in the dealing with mental dis- to bear. Both must work together to orders. We shudder at the guillotine, remedy the situation and crystaHze the dungeons, and the instruments of public sentiment to bring about the torture of the old France and wonder neces'='ary legislation. how a population could be content and The institutions of the state are full tolerate such brutality. Might it not with long waiting lists while county be possible that the years will come prisons house men and women awaiting when the people will look with horror berths in the state institutions. Some on our present treatment of our men- of these until very recently were chain- tally sick. We send to the insane hos- ed to the floor and had been for years, pital, yea asylum, for they are rightly And even in our state institutions the called that, a man or woman out of our inmates are not and cannot be properly community and in a few years we forget classified. The insane department of that the person ever lived. There the our state penitentiary has recently been person is confined year in and year out. publicly spoken of as a terrible disgrace What would happen to a normal person to our proud State. The superintendent under those circumstances. If the en- himself is much more disturbed about tire population of voters could take one it than we are. There are children in look into our jailS; "poor-houses," road our schools who ought to be in Dr. Mc- camps, and our state institutions for Nairy's school and there are people in prisoners and the mentally sick there his school who ought to be elsewhere, would a cry go out the like of which These children are holding back the nor- has never been heard in the Old North mal boys and girls who ought to be State. But the heads of the institutions pushing ahead. These boys and girls are not to be censured for this condition are juvenile delinquents, later our adult and this indictment is not being offenders. Large families come of this brought against them. They deserve stock and thus feeble-mindedness is pro- commendation for the work they have pagated. done under the circumstances. They In 1918 a special committee was ap- have been miserably handicapped for pointed by the New York Commission lack of funds. They have been crowded of Prisons to investigate the matter of beyond capacity and with a population mental disease and delinquency. The unclassified, among which were many following facts were found : persons not intended for the particular In state prisons 25 per cent feeble- institution. But the social service and minded. the health association, together with the In reformatories 26.5 per cent feeble- many allied agencies are gradually elim- minded. inating these disgraces, slowly but In penitentiaries and workhouses surely. Working with insufficient funds 33.5 per cent feeble-minded. and with scant personnel and fighting A survey is now being made of the the ever-present cry of high taxes, the county homes of our state and it looks Old North State is being recognized over as though 75 per cent will be found the country as doing some pioneer work, mentally defective. Let us see what the possibilities are as But we are coming into a new day in taken from the New Jersey experiment, this form of social work. Those of you "As a result of the treatment provided who have read "The Winning Fight during the last three years, 1,000 pa- Against Mental Disease," by Burdette tients classified in the so-called "incur- G. Lewis in the April Review of Reviews able" group have been discharged. In are familiar with what is being done in the last year 25 of this number have New Jersey. Experiments on a smaller been re-admitted, but eight of these scale have been made in other sections have been discharged after the previous of the country and the results are so inadequate treatment was completed, significant that I verily believe that we The discharged rate for the functional September, 1922. ORIGINAL COMMUNICATIONS 455 group has averaged 65 to 70 per cent temporarily then later another opera- of the admissions for three years as tion will be necessary. Whether the against a ten year average of only 37 theory of Dr. Cotton and Dr. Anderson per cent." that all mental troubles come from phy- If the tax-payers could only realize sical ills is correct or not, they have re- that $10,000 is a conservative estimate duced the average stay of curables at of the per capita cost of an inmate shut the hospital from nine to three months, up in an institution for life to say noth- I cite this wonderful piece of work to ing about the suffering of the patient show the possibility of handling this and the loss to the community of a citi- menace of problems in a scientific way zen when 70 per cent of these same and thereby in a successful way. It will per.sons could be returned to their com- cost money, yes lots of money, but it munities they would feel different to- pays because it is economical in the long ward the spending of money on such run. It is not only economical but it is institutions. It woud mean a tremen- beneficial to the patient, to the patient's dous .saving instead of an extravagant family, to the community and to society expenditure. Think of an institution for in general. A big part of our social the so-called insane with no strong problems would be solved if we could rooms, no straight jackets, no manacles put this plan on in North Carolina, of any kind, but instead, wards flood- Public Health officials and social ser- ed with sunlight, with white beds, with vice workers must because of their lead nurses in white just like the regular in the work. Those closely connected hospitals we are familiar with. And with the institutions will join us and why not? These people are sick, men- the public will soon follow if the pro- tally sick, and they need the kindliest of gram is definite. kind treatment while the re^adjust- We need a clearing house first of all ments are going on. Hear this para- where every man or woman convicted graph from Dr. Cotton's book, "The De- in any court must first go for classifi- fective Delinquent and Insane." cation. Experts would be there to give "Even today at least 80 per cent of thorough physical and mental examina- all hospitals for the insane throughout tions after which the sentence to the the country continue, to their own proper institution could be made. There shame and to the detriment of the pa- could be different classifications in the tients, to employ mechanical restraint, same institution but the prisoner would There is no necessity for it as the writer be placed where he could develop best can testify from personal experience, physically and mentally. And why not ? When he took charge of the State Hos- W^e do not want a wreck of a man unfit pital at Trenton in 1907 he found over for his family or society turned loose 90 women in straight jackets, and all upon the public. He would then be a other forms of restraint were in daily subject for another institution. A man's u.se. In less than two months over 700 mental and physical health should be pieces of restraint apparatus were re- conserved and not abused while he is a moved from the wards and since that prisoner. time no patient has been put in re- Possibly this same clearing house, or straint of any kind." the same experts, could be used for our Of what does the treatment consist? mental defectives, and our present state Possibly the extraction of an infected institutions be used under a different molar as is cited in one case. Eighty system of classification controlled by per cent of the patients have bad ton- the clearing house. Under this plan in- sils and they are removed. Many times stead of having long waiting lists be- stomach and intestinal disorders must cause of lack of room there would ba be made right by the surgeon's knife, more room because of the large number The operation may be very simple or of discharges. dangerously complex. Sometimes one I believe these things are possible, not operation will stay the mental delusions next year but within our generation. 456 SOUTHERN MEDICINE AND SURGERY September, 1922 Our Governor has shown great interest Teachers should be required to fami- in our institutions and progress is al- liarize themselves with this work, and ready being made. We must help do do it properly, or else they should be the job. relieved of this responsibility. I thank you. When I visit a school the first time for the purpose of examining the child- ren for physical defects, I have the prin- cipal assemble the whole school, and ex- PUBLIC HEALTH WORK IN THE P^ain to the children the purpose and cr'urkrk a scope of the examination. This I find SCHOOLS OF ROBESON COUNTY, stimulates cooperation and relieves fear. Pamphlets on adenoids, defective vision, ""■ ""■ Roirelon "count °^''^'' ^^'^•' ^'^^ ^*''^" """^ ^° ^^""^ ^^"^'^^ ^^P""^" oun y. sented in the school. Wherever possible My subject today is one of consider- J separate room with good hght is used able latitude, comprising as it does prac- ^"^ .fammation work, and if one is not tically every phase of public health aj^ilable it is obtained by having one work, as it relates to the school child, of the smaller grades dismissed and and the public school. "^^"^ its class room. The routine exam- I have tried to confine myself as far '"^^7" ?^^^^5'': T'' ^"^^^'S u as possible to a practical discussion of ^'^™P^f ' ^"^ often tedious and difficult work performed and methods used in ^.^^^ ^^^ '"^f^^' children I have found accomplishing same. ' ^^^,^, ^ ^f ^ "^^"y °^ , ^^^ ^^^^^ ^rade In Robeson County Schools, public f ^'^/,^" do not know their letters and health work is largely a rural problem, fo^ these the object charts have to be The County of Robeson has an area of "^^? ^"//?^ vision test. If the teachers 990 square miles, 163 public schools, and P^',^ ^^ the examination has not been 19,000 school children. It has been mv !^^?.^ properly, I make a complete exam- responsibility since September 1919 to 1"^^!,°" ^^ ^f\ ,?^^^' /"^ ^f7^ J^^ render public health service according teachers part of the card as well as the to my time and ability to this great f^'^'''^^ inspectors examination filled m. body of school children. Unfortunately ?" "^^ny schools where no cards have I have not had the assistance of a ?f^" "^^^? ^^^ ?^^f^^^.' ,^^^^, ?!^'." nurse in this work. blank cards, and instructed to do their When I accepted the position of Part of the examination as required by health officer in Robeson County Sep- ^^^- J\'' ^"^ ^fL teachers to tember 1919, I determined to devote a '^T ^^^^ T'^ °^ ^^""^ comphed with great part of my time to school work. ^^!?. ^^^^^^t. , . ^ , ^ Records on the physical examination , ^^"f \^^^^" ^°^^ ^" ^l^'^'l^r"' cards of the State Board of Health for ^7 f out two years ago the children Tviori-.r r^f <-v,^ „«u 1 • 4-u ^- ot all white schools, and the larger In- many 01 the schools were m the office, ,. , , , i i u u K,if r.^^Ac \.^A J u J -c 1 dian and colored schools have been ex- out cards had not been made for a great ■ ^i j! u-ij4?+ r\ t- f many more. A great many of these T""! ^^f P^^^^^/ ^^^^'^', ^"^ °^ cards were of little value as the teach- ^^l ^^f, ^^°"^^^"^ examined approxi- ov'o i,n^ ^r.i- ,„,^^ ^ ^ u ^ 1 1.1. matelv 35 per cent were m need of oper- ers had not understood how to make the .■ ]e ■, j 4. -i j j -j ovQrv,,-r.of,-^v. . 'ii 4.U • ^ atiou for enlarged tousils and adeuoids, examination especially was this true ,a ^ x. j j £ 4-- ■ • j ^f fv,^ r,^^' A u 1 Tx/r ^ 4-1, 10 per cent had defective vision, and of the colored schools. Many of the . o \,_ „„„. ^.fp^tivp hearino- Nine teacher's consider this work a nuisance, ^''^ per cent detective hearing. Nine .,„. .^^ ,•-,, . , 4. • •. T xi_- / per cent of those with enlarged tonsils and take little interest in it. I think ■, ■, ••, ^ j4.u- 4. +u^ ;^A-4r 4. 4.4.-4- J ^ 4.1 11 and adenoids were found to be m urgent the indifferent attitude of the school „„„^ „^ „,. „ tt„i„„. ^u. aJ^„^^ auhorities is largely responsible for this need of operation. Unless the defects of vision and hearing was greater than eight over ten I rarelv recommend ex- 25-27. 1922. visits to a school I find that a great September, 1922 ORIGINAL COMMUNICATIONS «7 many of these children previously ex- amined have had their tonsils and ade- noids removed, or their vision corrected by glasses. I had 57 of these tonsil and adenoid cases operated on in a State Tonsil Clinic. More than half of all children examined were found to be in need of dental treatment. During the last four years we have had 2,000 of these children treated by dentist from the State Board of Health; many others have been treated by the local dentist. On account of the frequent moving of tenant families, the change of teachers, and the custom of many child- ren staying out of school to do farm work, it has been impossible to get ac- curate data as to the number of school children having defects remedied. In many of the schools one or more children were found that were mental defectives, either from inheritance or other cause. An effort is made to place as many of these as possible in the State school for the Feeble Minded, where they will have a chance, and to take them out of the already crowded schools where they have been a drag often for years. I have found a number of school children with orthopaedic defects, most of them following infantile paralysis. I am endeavoring to have all these children that can be benefitted, treated at the State Orthopaedic Hospital, Gas- tonia. Our efficient Welfare Officer, Miss Elizabeth Frye is taking an active interest in this work, and usually ac- companies the children to the different institutions. Realizing the great prevalence of hookworm infection among the child- ren of the County, and the roll that the rural school insanitary privies or no privies at all, play in the spread of the disease, I have made a special effort to get two sanitary privies at every rural school. This was done by taking up the matter with the school committeemen and teachers, and explaining to them the importance and necessity of sanitary school privies. A great many school privies were built; in fact too many to suit the Superintendent of Schools, as he complained that the committeemen were having them built, and then bring- ing him the Dills for same, when h^ didn't have the funds to pay them. Inspection work in the white schools showed such large number of clinical cases of hookworm, disease that I de- cided to make microscopical examina- tions from schools in all parts of the county, to ascertain the per cent of in- fection, and at the same time to treat those found infected. Specimens of stool from 1,040 children in 28 schools were examined with the microscope, and 427 or 40 per cent were found to be positive. All of these were given three treatments each oil of chenopo- dium. Specimens from 98 of these children were re-examined, after they had taken three treatments for hook- worm. A good many of these children however did not take the treatment given them. In the above examination the specimens were not centrifuged, di- rect smears were used, and one large slide made as a rule for each specimen. Contagious diseases have made their inroads on the schools of Robeson Coun- ty, as in other parts of the State. In 1919 and 1920 it was mainly diphtheria, measles, and scarlet fever, 1920 and 1921, diphtheria, whooping cough, and measles, 1921 and 1922, chickenpox, whooping cough and diphtheria. When a contagious disease breaks out in the school district the teacher is promptly notified of same, and instruct- ed to exclude all children in families where the disease is present. When possible I visit the school, and discuss the disease with the teacher and child- ren, and try to enlist their cooperation, and urge them to report any other cases in the community, promptly to my of- fice. Literature on the particular dis- ease is given out to the children to take home. I find that teachers often allow children to come to school with a conta- gious disease when they have suspected the trouble. The indifferent attitude of many parents is largely responsible for this. I have found that a few careless or intimidated teachers, and a number of hard-headed, ignorant or misguided parents are responsible for most of the spread of contagious diseases in the schools and community. 458 SOUTHERN MEDICINE AND SURGERY September, 1922. I have observed that diphetheria re- ports each year from certain communi- ties are always high. This is probably due to the presence of "carriers" in such communities in our County. I de- cided to try out the Schick Test in the schools of these communities, and 1,110 children were tested, approximately 30 per cent of these showed positive. Three hundred and twenty-six children found positive were given the complete anti- toxin preventive treatment. The work was not satisfactory, because the par- ents of a large number of the younger children refused to have them tested, although a long letter of explanation had been sent them. The toxin for the Schick Test was obtained from the New York Laboratory. My experience with the Schick Test, though limited would lead me to believe that it is impractical for routine use in the schools, but that it might be used to advantage in the communities where the incidence of diphtheria is always unusually high. In such instances all children should be re- quired to take the test, and if found to be positive, should be required to take the toxin-antitoxin preventive treat- ment. When we consider the fact that many counties have a law requiring all children to be vaccinated for smallpox, when smallpox is spreading in the school community, this does not seem unreas- onable. An effort has been made to vaccinate as many school children as possible against smallpox, for future protection to the public as well as the school. This has been confined largely to the colored schools, as nearly all our smallpox has occurred among the negroes. Smallpox has not been reported in the schools at any time, and only two cases have been reported in the County this year. Thir- teen cases were reported in the County last year. After several unsatisfactory exper- iences I have concluded that compulsory vaccination should be restricted to school communities in which smallpox is present. We have a law in our Coun- try that requires all school children in the district to be vaccinated when small- pox is present in the district, and this law has been enforced thus far. My best results, however, have been obtain- ed by the voluntary method, the work being confined largely to the colored schools. Since January 1920, 3,162 school children have been vaccinated for smallpox. When I visit a school to vac- cinate for smallpox, I have the principal assemble the whole school and try to give them a good word picture of small- pox, and smallpox vaccination, and the necessity of being vaccinated. I then pass out to the children the State Bul- letin on Smallpox and let them get the actual picture of people with smallpox, and people with vaccinations. After this they are told to roll up their sleeves and get in line if they want to be vaccinated. They fall in. Call it mass, psychology or what not I have vaccinated 80 to 100 per cent of all children present in the schools that I have visited for this pur- pose. I use the State Board of Health vaccine, and have gotten 90 per cent takes in all instances where the vaccine used was reasonably fresh. I use the army method in vaccinating, namely, making two parallel scratch marks well spaced on the upper left arm. The arm is cleaned with alcohol and no dressing is applied after vaccination. Iodine is left with the teacher, and she is in- structed to paint the vaccination wounds daily from the sixth or seventh day for a week or more. In this way out-side infection is avoided when the scab is scratched off. I have had no bad arms where this method is used. The work has been for the most part pleasant, and I feel that a great amount of good has been accomplished ; but when I think of the thousands of school children suffering for the need of a simple operation, I am forced to con- clude that the medical profession is neg- lecting a great opportunity to strength- en its position with the public, in this day of quackery and new cults. The problem of moving the physical handicaps of the public school child, is a big one, and will require the active medical profession, and the public. The medical inspection work in the schools has prepared the ground for the ulti- mate solution of this problem. The pub- September, 1922. ORIGINAL COMMUNICATIONS 459 lie will place the responsibility for its aj^-cl brisfly to mention the various ab- solution on the medical profession where tivities of health work in the schools it rightly belongs. If we are to merit of Winston-Salem during the past few this confidence, on the part of the pub- years, and to call attention a little more lie, then we must adopt the policy of in detail to one or two features which Service First. If we recognize the med- to us have been very interesting, and, ical profession as a creature of society, we think, worth while, then it is our duty to seek the good of We have 10,000 enrolled school child- the social whole, knowing that our ulti- ren. Five or six years ago the first mate good is wrapped up with it. systematic health work in the schools As Dr. McAfee has so well said, in his was begun. At that time, the health admirable paper, "We may need to oflFicer and two nurses, one white and stand together for justice in the days one colored constituted the staff of that are to come; we may need to wit- school health workers. The work has ness strongly for truth ; but we shall grown here, as everywhere, and the not have to fight for existence, so long staff" has gradually been increased Un- as we follow the path of Service; for til consisting now of school physician, whoso thinketh to save his life shall devoting practically all of his time to lose it ; but whoso loseth his life for school duties, health off'icer, who does my sake shall find it." some school work, and 10 nurses and supervisor. Of the nurses seven are school nurses proper, two are nutrition workers and one is the directress or executive leader of the Modern Health HEALTH WORK IN THE SCHOOLS.* Crusade. Health work in the schools of Win- Dr. R. L. Carlton, ston-Salem is definitely under the super- Winston-Salem, N. C. vision of the department of health. No . , , . part of the expense of this activity is Among the resolutions adopted at the bo^ne by the board of education, which Cannes Conference m 1919 occurs the board however is thoroughly in sympa- followmg: ^by with health work and cooperates "That the training of school children fully, in all grades by thoroughly qualified Examinations, as schools begin, find teachers in the subjects of personal some diseased conditions, for which hygiene and the inculcation of proper temporary exclusions are made, and health habits during school life are many physical defects. No written perhaps the most important undevel- notices are sent to the parents concern- oped measures for permanently im- ing the child's defects but the nurse proving the health and contributing to makes a personal call and follows this the welfare of the people." Dr. L. Em- with another visit and another and an- mett Holt endorsed the resolution not other if necessary — until finally the long ago and continued by saying: "No very persistence of the nurse, if noth- matter what particular phase of the ing else, gets the attention of the fath- health field we are considering, in the er or mother to such an extent that the last analysis we come to the fundamen- defect in question is corrected, tal fact that progress depends upon the Nearly one hundred children had dis- personal hygiene of the individual, his eased tonsils and adenoids removed last food, his health habits, etc." year as a result of this activity, more It is not my intention to attempt a than fifty of this number having the discussion of the entire program of necessary operation without cost to the health work in the schools, but simply parents. Other defects were corrected — — in like proportion — more than 1,200 *Read at the Public Health and Education ^ujiHrpn VinH frPP Hpntnl wnrV rlnno Hnv Session of N. C. Medical Society, Winston- Children had iree dental work done dur- Salem, April 27, 1922. ing the three months last fall — the point 460 SOUTHERN MEDICINE AND SURGERY September, 1922 is, a large proportion of these children ularly and for a certain number of weeks would not have had t^is corrective and for doing which they are given rank treatment done but for this work in the of page, squire, knight, knight ban- schools but would have gone along nerett, etc., and are awarded certain handicapped through school and pos- buttons, badges and certificates to de- sibly through life. note their rank and standing among The prevention of sickness then, by their fellows. When these things are the prompt recognition and exclusion put up to the children in a story telling of ailing children and securing the cor- way by teacher and nurse and Crusade rection of physical defects make up an Leader and in addition the spirit of corn- important part of the school health pro- petition between the different groups of gram. children is installed, and their interest The program to be most effective is kept up by songs, health plays, etc., must go further than this, however, all through the year, they become very and must so train and instruct the enthusiastic and the changes wrought child that he is given a correct set of in some of them are little short of mar- health habits and an understanding of velous. One father told me he was as- the hygienic conduct of life. The pro- tonished that his little daughter who gram, therefore, should be made up of would not drink milk and could not by health protection, correction of physical any parental devices be persuaded to do defects and health promotion. It is in so, immediately decided that she must relation to health promotion that I wish take not less than two or three pints of to say something of the Modern Health milk daily when she was informed by Crusade and special nutrition work. the nurse that she was underweight and Modern Health Crusade. We have the Crusade Leader told her she was had the Crusade in Winston-Salem not keeping up with others in the schools for some 3 or 4 years but be- "health game" and that she was vio- cause of scarcity of nurses and lack of lating some of the "rules of the game." interest of teachers, which lack of A mother was pleased but somewhat seeming interest was due to lack piqued when she discussed the Crusade of time for this particular work, the with the leader. "It's postively discour- movement did not attain the success it aging," she said, "to learn that a perfect deserved. At the beginning of the 1921 stranger can convince Tommy in a half school year the Crusade was placed on hour, that he should brush his teeth, a more substantial basis than it had when after years of trying, I haven't been before. The time of one nurse is impressed him at all. He came home one given entirely to this — she is called our afternoon and announced that he must Modern Health Crusade executive and brush his teeth twice a day as though is made responsible for the maintenance he had never heard of it before, and of groups of Crusaders in every school, now he actually does it and seems to 40 classes of nearly 1,500 boys and like it." girls are enthusiastic Crusaders in our The secret of the success of the Cru- schools now, and that these youngsters g^cJe is not far to seek. It makes the have derived benefit from this organiza- practice of health a game. The pupils tion there is no doubt. learn by doing. Health habits are en- The Modern Health Crusade seeks to couraged and established by group ac- put into practice health education in the tjon. Washing the hands before meals, pubHc schools. It has made instruction cleaning the teeth, sleeping long hours in hygiene practical for it has put the ^nd with windows open, exercising in child to doing the personal health duties the open air, eating slowly, wholesome that have previously been defined in ^^^^ ^^^ taking deep breaths and fre- hygienic classes but have not been done. ^^^^ ^^ ^^ ^^^^ ^^^ ^^ The Health Crusade, as you all know, ^ ,, ^ is really a game made up in a most in- matters of course. teresting way of health rules or chores Altogether it is believed that the Mod- which the children are to observe reg-ern Health Crusade with its health rules September, 1922 ORIGINAt. COMMUNICATIONS 461 or chores, its prizes and awards of rank, undernourished children were from .•1 recognition from time time of little homes of the poor there were quite a health plays enacted by the children number from well-to-do families or even themselves, keeps them interested, goes from homes of wealth. The matter of a long way toward making these things nourishment then, or rather, lack of become lasting, fixed habits and really proper nourishment was seen to be one points the way to a successful method of not knowing just what foods the child of teaching personiil hygiene in the should have more frequently than was schools. It has been gratifying to note supposed to be the case. Children who with what interest and persistence the are underweight, are generally puny, hundreds of our children did their anemic, flabby muscles and have a ter- chores, received their rank, etc.; it has ribly difficult time keeping pace with been pleasing to note from time to time their more robust mates, either lagging the requests of teachers and pupils of behind in their classes or holding back grades in which there were no crusade with them the entire group. They are classes that they be given this work easily fatigued and find it next to im- also ; and it has been very interesting possible to take the active physical exer- to note with what zeal the colored child- cises they should be taking and enjoy- ren go about this phase of health work, ing. They are the children who are most the Crusade Leader reporting that a frequently sick and who are susceptible smaller percentage of colored children to the communicable diseases— especial- drop out for various reasons before com- ly is this true of tuberculosis. It is pleting the period than is the case with common knowledge that anemic, under- the white children. nourished children are easy prey to tu- We are glad to learn that the National berculosis if exposed to it. Tuberculosis Association is now work- To properly care for these children ing on the material for graded courses and have them attain such physical of Crusade work and that this material condition that they would no longer be will be ready before the opening of listed among the "underweight" and schools in the autumn of this year. This "mal-nourished," it was recommended grading will undoubtedly add much to that special classes be formed and that the interest of the Crusade in different experts in matters of nutrition be placed school grades and will enable it to be in charge of them. carried on for longer periods of time. The American Red Cross made this We plan to extend the Crusade here to possible by giving us last year two many classes next year which did not workers, one white and one colored wo- have it before. We hope you will all be man, who know how to teach little present tonight when a group of Cru- folks the things pertaining to diet and saders from one of our schools will pre- nutrition in such a way as to make it sent a little health play entitled "The attractive and desirable that they gain Health Champions." weight and reach "normal." Nutrition Classes. Several hundred children were group- The systematic weighing and measur- ed into "nutrition classes." No child ing of the school children had shown was enrolled who was not 10 per cent that there are a number who do not or more below normal weight. The weigh as much as they should at a given school physician and nurses assist in age and a certain height. A careful go- locating in the children any diseased ing over of these children showed that a condition or physical defects which majority of them are undernourished, might prevent their being "free to gain." or are suffering from malnutrition. Teachers, nurses and directors of these Children of this class were not confined classes unite in trying to determine to any particular section of the city or what- the home conditions of the child to any special school but some were are, whether there is good home control, found in almost every room of every whether he is worked too hard outside school, and, while a majority of these of school hours, whether there is lack ^^2 SOUTHERN MEDICINE AND SURGERY September, 1922. of proper food on account of economic at the school house for mothers only, conditions and whether the health hab- when they explained to them in detail its of the child are good, etc. what is being done for their children In the classes instruction is given in and how the help of the mothers is matters pertaining to nutrition in needed. Such meetings have been well terms of cereal and vegetables, rather attended. than of protein, fat and calories — the These classes afford interesting study, children are told just what to eat Not all the children have gone "over the and how they should eat in order to top" of course, but a goodly percentage become strong and robust and en- of them have and almost all of them able them to develop into real men have shown gains where it is possible and women. They are encouraged to to do so. make use of the lunches provided at the Nutrition class work has been done in lunch rooms of most of our schools. If our schools less than a year. The work- the child brings a cold lunch with him er in the white schools only a few weeks from home he is encouraged to buy ago awarded 60 children certificates of something hot to eat with it. It is es- graduation as having reached normal pecially pointed out to them that milk weight for their age and height and has is one of the most important articles dismissed them from the nutrition of diet and that many of them are un- classes. She tells me there are at least derweight simply because they are not 75 other children who are now within drinking enough milk. They are en- five pounds of normal weight and will in couraged and urged to drink milk which all probability be graduated and receive is supplied to them at all schools at re- a diploma before the schools close. The duced rates, and in many instances is children call this "eating for a diploma" given to them — at least a pint a day and show much interest in their charts without any cost. and diploma but almost invariably ob- Each child has his name placed on a ject to being dismissed from these class- large chart on the wall of the room and es. lines are drawn showing what the child It is not claimed that nutrition work should weigh and does weigh ; at the in the schools is any more than one part weekly meetings he is weighed and the of a good health program, but it is an weight line on his chart is extended ac- essential part and has proven its value cordingly. The child becomes interest- by definite results. ed at once in noting whether his weight We have all seen many undernourish- goes up or down and it is not difficult ed children and considered it nothing for a worker who knows the game to unusual, but when one looks into the cause the child to become willing and pale faces of 75 or 100 undernourished anxious to do as nearly as possible children one is impressed with the fact everything he should to gain weight. that there is something wrong some- This work in the schools is supple- where. If all the severely undernourish- mented by periodic visits by nurse, ed children in Winston-Salem, or any teacher or both to the child's home, to other city, could be brought together, secure the assistance of the parents in it no doubt would convince the most having the child follow a definite regime skeptical that more attention must be in respect to exercise, hours of sleep, given to mal-nutrition. periods of rest, the eating of proper food We repeat, in our opinion, the well and ventilation of the bedroom, etc. rounded program of health work in As often as possible the mothers of schools should be made up of health the children in these classes are asked protection, correction of physical de- to meet with them in their regular week- fects and health promotion, and that ly session.. Good results are secured in important places in health promotion this way. are occupied by the Modern Health Cru- Again, the nurse and nutrition work- sade and Nutrition classes. Such a pro- er have from time time held meetings gram is practical, can be applied to the I I September, 1922. ORIGINAL COMMUNICATIONS 463 rural schools of 100 pupils or the city's thorities, etc., throughout the country. r-;oup of schools of several thousand In weighing the evidence presented students and is no less than our boys from such sources he concludes it is and girls should have if we hope to de- impossible to paint a finished picture of velop our future citizens as they should the whole situation and selects outstand- be developed. ing features of programs and activities, fitting them into a mosaic, which, in or- der to gain its perspective — must be viewed at a little distance rather than PROGRESS OF CHILD HYGIENE too critically close at hand. With Dr. Bolt's permis the pleasure of presenting The Progress of Child Hygiene Work in WORK- TM THF IT G ^^^^ ^^- ^^^^'^ permission, I have wuKK ir^i int. u. ti. ^j^g pleasure of presenting his views of Rose M. Ehrenfekl, R. N., -u tt o «. Another marked sign of progress, the other hand a few day nurseries and therefore, has been the demand of state kindergartens have realized that there and local organizations for people es- was an excellent opportunity of extend- pecially trained along child hygiene ing their influence along health lines lines, and the promotion of local inter- and they have provided medical inspec- est by educational courses. tion and nursing service. While the well-worked-out methods (A great deal remains to be done in for the infant in arms are still widely the way of standardizing the methods applied, used and of coming to some conclusion 7. There has been an extension of as to the most practical way of handling child hygiene in two other directions: this preschool problem.) first, in the prenatal period, and second, The past year has witnessed a notice- in the preschool, and school ages. Not- able advance in our knowledge of the able work along maternal lines in sev- causes of mal-nutrition in school children eral large centers has demonstrated and the extent to which it occurs. Very what could be accomplished in reducing definite steps have been taken in the maternal and neonatal deaths by well way of proper education of the mothers conceived and well executed plans. These and teachers along nuritional lines and have stimulated other localities to in- also the actual setting up of nutrition stitute some form of maternity work, classes in very large numbers of the In some places this start simply con- public and private schools throughout sists in verbal instruction by the nurses the country. ^^^ SOUTHERN MEDICINE AND SURGERY September, 1922. 8. There has also been a definite ad- can see considerable progress, viz: den- vance in standardizing weights and tal hygiene and correction of malnutri- heights in school children and in our tion. The need for better care of child- knowledge of what actually constitutes ren's teeth is stressed everywhere, and causes of mal-nutrition in school children communitites in all directions are tak- 9. During the past year there has ing steps to correct dental defects. (This been much study for the prevention of has been shown mainly along two lines: tuberculosis in infancy and childhood, first, an attempt to supply sufficient den- As practically all initial tuberculous in- tal help either through the dental socie- fection takes place in childhood, this is ties, or by aid of dental hygienists to a very logical development and a real correct the simple defects, scale the sign of progress. teeth, and fill simple cavities for school 10. Our newer knowledge of syphilis, children. The tendency has been to and the method of preventing its con- push the age at which dental care is genital form is leading to more strict at- given back earlier and earlier into the tention to the possibilities of syphilis pre-school age. Along with this has among pregnant women, and to its early come a large amount of instruction along and intensive treatment in hospitals and the lines of dental hygiene, and actual dispensaries. demonstrations in the public schools. 11. Throughout the country there Second. An attempt to secure better has been a sincere effort on the part of nutrition of children of pre-school age many to secure more uniform record and to give hygienic treatment in this! forms— to do away with non-essentials, period. There is a growing feeling thatj and to make the records really service- in order to be most effective dental hy- able. giene should begin in prenatal life, anc (Even among those who have found that proper nutrition is one of the mail it difficult to compile complete statistics factors on which we have to rely as relating to their work, there is an ad- basis for sound teeth.) mission on their part of the necessity The nutrition work has not only been for standard forms. This is especially carried out through voluntary societies, true in the case of preschool record but is stimulated by Government Bu- forms.) reaus and through public schools. The 12. Throughout the past year there educational side of nutritional work has has been a distinct recognition of the also received a great impetus through reed of proper care in certain types of attractive and definite instruction. The disorders and special classes have been demand for literature, charts and pro- formed here and there in attempting to grams along nutritional lines has been work out good clinic methods and overwhelming. (Considerable, however, standards. Most notable of these special remains to be done to harmonize some classes have been those for the care of of the programs, and to present a solid cardiac cases ; for posture (including the front in educational lines along nutri- after treatment of infantile paralysis) tional lines.) and for malnutrition. (In some cases 14. As child hygiene work has devel- these special classes have been formed oped, an(t rural centers have become simply as part of the regular clinical more and more interested in it, a great- routine. In other places entirely separ- er demand for an extension of child ate classes have been provided not only hygiene work into rural communities for the examination in the clinics and has come. This has been met in several prescription for treatment, but also for ways. Throughout the country there actually carrying this out. Special has been a growth in local health cen- classes for malnutrition and posture ters which have been set up as health have in a number of instances been ex- educational centers. Through which the tended to the public schools.) work of the public health nurse, and in 13. Two features of the year's work many cases child welfare work have in child hygiene stands out in which we been extended. In several states an ex- September, 1922. ORIGINAL COMMUNICATIONS 467 cellent beginning has been made in the nent concrete results as smaller confer- extension of child welfare work to rural ences at regular intervals, districts through the State Bureau of 15. In the country as in the cities Child Hygiene connected with the there has been a great demand for edu- State Boards of Health. This has been cational films along child hygiene lines. carried on through educational work by (Although several films have been put personal conferences of members of the out through the past year it is still true child hygiene staff, and also through that this field is wide open for future giving post-graduate courses along child developments.) The use of telling, well hygiene lines to the physicians in the worked out films for fairs and nutri- smaller cities, and affording them facil- tional exhibits throughout the rural dis- ities for consultation. tricts would undoubtedly accomplish a Another line of approach has been ^^eat deal of sound educational work, the use of traveling health dispensaries ^^- Inuring the past year there has which have taken on two forms, one *>een considerable activity along educa- b€ing used purely for education and tional lines in regard to child welfare. proDiganda, and the other for carrying A number of states have appointed spec- on actual examinations of the children ial Children's Code Commissions which and for applving simple treatments, were instructed to make a thorough The traveling health dispensary seems study of child welfare laws, and to pre- to have justified itself as a method of sent their report at the Legislatures education and a means of health com- which met during the year. These were munication between various isolated presented in many states. It is unfor- rural districts. (It is, on the whole, an tunate that many of the Children's Code expensive method, and it is questionable Commissions laid the greater stress up- whether with a well-equipped auto on the care of the dependent, delinquent truck, it is advisable to carrv on actual and defective children, and considered treatments in the field, although dental «"!>' incidentally the health phase of prophylaxis and in .some cases adenoid child welfare. and tonsil removals have been carried l^- ^11 studies during the past year on with good results ) have pointed to the great need for bet- Another method which has been pop- ^er standards of work, and definite prog- ular, but upon which there is now con- »-f « ^as been made in erecting^ certain siderable difference of opinion as to its standards for the health of the child permanent results, has been the setting »" industry and in setting up minimum up of child hygiene clinics or demonstra- ^^?"7Tf>' ^f'^^^ '^'^ . /T tions at State Fairs. (There is a de- ^^^^ool child. (The previous standards mand for this and no question but that f * up for prenatal care and care of in- a large crowd can always be gathered fants have been thoroughly tested and J u i.1- • u- u u u ^ found, on the whole, to answer the around a booth in which babv confer- ^""'"^'' ":' *- ^ • - • u j u • A i. J u 4^ 4-u ^^ needs. It now remains to give a broad- ences are being conducted but the per- ". , ^ ^, i.jjj u , j\.-r. u i-ujer trial to these standards and see how manent good which can be accomplished ^, '■'''* , , , , . . , , . . 4-- ui \ A they can be worked out in varied prac- on such occasions is questionable.) A "^^J' »-" ^ number have raised the question as to ^^^^-f whether it would not be better to uti- 18- One of the distinct signs of prog- lize monev and strength which are re- ress along the preventive side has been quired for fairs, and set up regular con- the immunization of a considerable num- ferences at various localities through- ber of children, between 6 months and out the state over much longer period 6 years, against diphtheria infection. of time. In other words the State Fair The time has been too short for a com- ^ ^ ^ • •.• , plete .ludgment in regard to this immu- Conference are more of an initial pop- nj^^tion but the preliminary work has ular presentation of a propagandist na- thoroughly justified the statement that ture but are not very constructive. Nor this is an extremely inportant matter do they give to the mother such perma- and one which should be adopted in fu- A. A. Barron, M. D. Charlotte, N. C. 468 SOUTHERN MEDICINE AND SURGERY September, 1922 ture child welfare work. (It can be easily applied through the child welfare AN INTERESTING CASE OF centers, or through kindergartens and APHASIA. day nurseries.) 19. Continued progress has also been made in the extension of breast feeding The following case is of considerable through a number of infant welfare cen- interest because of the character of the ters in different parts of the country, aphasia present. The lesion I believe Extensive campaigns which have been primarily to be a left temporal lobe carried out in several large communi- t"^'^^'; ^ ^^f^ ^° ^^^^"^^ ^^^^^^^ ^^^ , . , ,, . , J ^ ^ T XI X aphasic symptoms. ties have thoroughly demonstrated that ^he term "Ahasia" means literally a larger number of mothers can be in- the loss of power of speech. It was duced to nurse their babies at the pres- used originally to indicate a condition of ent time than we had formerly supposed, those who from accident or disease ef- This improvement has been made pos- Meeting the brain had lost in part or in sible bv earlv reo-istratinn of births entirety the power of expressmg them- sible by early registration ot births, selves in spoken words ; but the term as and the follow-up of each newborn baby ^ general expression is now extended to in these localities. This type of work include those who are not able to under- has added materially to the value of stand spoken or written language, etc. infant welfare stations as centers of in- —that is, those who are word blind or struction not only of the mothers them- word deaf. Aphasia is a symptom with , , ^ ., ■, . • which we are frequently confronted and selves, but of pupil nurses and physi- ^^^^^^^ ^^ -^ ^^.^^ ^^ -^^ ^^-^^ ^^ly ^ ci^i^s. symptom and not a disease it has been Summing Up Then. The items of dis- a center of controversy for years, a tinct progress during the year we see, controversy which seems to be awak- first, a continued and widespread inter- ening again in these days. The intri- est and demand for educational material cacy of the subject of aphasia is due „ ,. .,.,,, . IX largely to the fact that it can be ap- along all lines of child hygiene, but es- preached from an anatomical, physiol- pecially that which concerns prenatal ogical, and psychological side alike and and nutritional work and the child of investigators have not always been pre-school age ; second, while public in- careful to avoid inappropriate transfer- terest has been aroused and maintained f ^e of terms or even of conceptions . , „ -, J , , from one system to another. It is not It now remains to follow up and crystal- ^^^^^^^^ therefore, that the interpreta- lize it m well-worked out concrete pro- tion of the various forms of aphasia grams which cover the whole period of have given rise to a great deal of infancy and childhood; third, although theoretical speculation. in many places appropriations have been New lights can be thrown on the sub- , -. • A A r *-■ ^ i-r. fv,^ ject only by careful clinical study 01 cut, enthusiasm and devotion to the ,.,.:, . • -, ^i„+;^„ „ patients with aphasia and correlation work has caused a number to carry for- ^.^^ autopsy findings. Unfortunately,; v^^ard work already begun, fourth, there many of the cases are so complicated! has been a distinct advance in keeping that complete studies can not be made] of records and of reporting births— and, nor the exact condition determined. fifth, there has been developed a better Word blindness is one of the less com-j , , ,. , , • J- -J 1 „„^ riio.i forms of aphasia. Two types havel understanding between individuals and ^^^^ described: the first called by De- asociations and a sincere effort has been -^^^^^ ..p^^^ ^^^^ blindness" is char- made to bring about a coordination of acterized by an inability to read writ- child health activities." ten or printed words, but with the pre- September, 1922. ORIGINAL COMMUNICATIONS 469 servation of ability to write. This form which he was able to be up. Two weeks is usually accompanied by a right later had another and 5 days ago an- homonymous hemianopsia ; 2nd, rarer other, the latter two being less severe, type combines visual aphasia with Since the second attack 5 weeks ago agraphia or inability to write. Ordinar- he has been very nervous, worried ily, there is no hemianopsia in this about his work and slept poorly. For form, speaking anatomically, as the several weeks, it has been noticed that lesion of the angular and marginal gyri he had difficulty in finding the right is more superficial and does not extend word to use frequently when talking. He into the optic radiations or gratiolet. not infrequently uses the wrong word. In word deafness or auditory aphasia, mumbles his words and has been unable the sounds of words are not distin- to read or write to any extent for several guished by the patient from any other weeks. It is rare that he makes any at- sounds but his auditory engrams are uti- tempt. His condition otherwise has re- lized for reading, writing, and speaking mained good and he continued his efforts though one can not repeat words or re- at farming until a few days ago. Fre- quests and can not write to dictation. quently, however, he appeared some- The case reported below is somewhat what confused and his memory has complicated showing practically com- seemed to be poor at times, plete word blindness and agraphia with Physical Examination. hemianopsia, some word deafness and Patient well developed adult of medium paraphasia, but no anarthria. stature, in a good state of nutrition, gen- History, eral visceral examination negative, B P The facts of the family and personal 120-80, radials soft, urine negative, history obtained partly from wife: blood studies negative, spinal fluid in- Case No. 1012, male, white, age 42, mar- eluding Wassermann, negative, cell ried, farmer. The family history has count 3, X-Ray of head negative, no bearing on present condition. Past Gait and station normal, station good history shows nothing of importance ex- on either leg alone, hand grips of right cept that for several months he has — is right handed — is probably slightly suffered with headache and his wife weaker than left — face when at rest or says that on sev^eral occasions he has on movement presents no inequalities, said that he saw double. His wife is tongue protrudes in midline, no tremor in good health, has three healthy child- of tongue or lips, no ptosis of lids or ren, wife no miscarriages. Does not use exophthalmos, tendon reflexes slightly alcohol or tobacco and denies venereal more active on right side, there is a sug- disease. His education consists of a gestive Babinski on right, finger to nose country school education — was able to test reveals some ataxia more noticeable read and write and attend to ordinary in right, has some difficulty in recog- business concerning his farm. nizing objects in right hand, pain, ther- Present illness began about 5 months mic, and touch senses appear normal, ago while working on his farm when Ptipils equal, regular, and react normally he suddenly experienced a numb sen- to light and accommodation, examina- sation in his arms and legs. This was tion of fundu fails to reveal any evi- followed by headache, nausea and vomit- dence of an optic neuritis, arteries and ing. He went to his home and after re- veins normal and no signs of pressure, maining in bed for about 24 hours he fields are difficult to interpret under the was sufficiently relieved to permit his circumstances but there appears to be getting up. The headache continued, some limitation of vision to right. Ex- but much less in severity. He soon re- amination of sense of smell and taste turned to light work on his farm and unsatisfactory but apparently normal, suffered no particular inconvenience un- Mentally patient is well orientated, til five weeks ago when he again had a memory somewhat deficient, a little ap- somewhat similar attack. His acute prehensive, excitable, anxious to cooper- symptoms lasted about 2 days after ate. 470 SOUTHERN MEDICINE AND SURGERY September, 1922. ' Statements of wife in regard to pa- to carry out instructions fairly good. tient's speech were abundantly confirm- Examination of eyes at this time reveal- ed during examination. He sometimes ed right homonymous hemianopsia, mumbles his words, but no definite jar- fundi were negative. Was able to recog- gon. In reply to questions as to how he nize objects in right hand, suggestive feels ard of what he complains, at times Babinski on right, no paralysis. He got gives unintelligible answers and at times from under our observation and died fairly intelligible answers. He frequent- some several months later, ly uses the wrong word as, for instance, It will be noted that the aphasia pres- when asked how he feels, says, "Good." ent was sensory in type. There was In a few seconds seemed to realize his practically complete word blindness in mitake and said, "I mean bad." Once that he was not able to read even sim- when asking for shoes, in pointing to- pie words ; agraphia practically complete ward them said "hat." When speaking in that he was not able to write simple of his wife, he frequently says "he" words ; there was some auditory aphasia instead of "she." and some object agnosia; some para- Fails frequently on simple spoken in- phasia; some aesteriognosis in that he structions such as "put out your ton- had difficulty in recognizing objects in gue," or "put one finger on your nose, the right hand. The lesion, primarily, After a time, he occasionally seems able is believed to be in the left temporal lobe but at first caught his foot, then placed and it is thought to be glioma with both hands on head, then index fingers hemorrhage, though it may be vascular of both hands on nose. lesion primarily — aphasia resulting be- When a number of objects are placed cause of the increased pressure inter- before him and one object named, he fering with the associating tracts of sometimes picks up the object named, sensory centers. at other times, he fails. When asked to read even simple words, he spells it, usually aloud. Sometimes he is able to recognize a word and sometimes he INFECTIOUS DIARRHEA." fails. In spelling long words, though By Needham B. Broughton, A.B., M.D., the letters may be read, he becomes con- Pediatrician to Rex and St. Agnes Hospitals, fused and is either unable to recognize Raleigh, N. c. the word or misread it. He is able to repeat words fairly readily except those Nothing offers greater opportunity having several syllables. ^or differences of opinion than an at- A pen is placed in his right hand temp at classification of intestinal disor- and he is asked to write something vol- ^^^^ in early life. It would be difficult untarily. He produces something which ^^ ^^^ ^^o pediatrists agreeing abso- is practically illegible. Asked to copy lutely on any one selection, a sentence he makes a series of unintel- Difficulty in classification is due not ligible marks. Asked to write the al- only to the fact that fermentative diar- phabet, he makes "a" then "g" very rhea may simultate infectious, but to the poorly than makes a series of curved fact that mild cases of dysentery may lines. Asked to multiply 3x3, he puts pass unrecognized owing to the absence down a very poorly made figure 3 three of pus or blood in stool. It is the mild times. unrecognized cases which are not im- After remaining in Hospital for sev- probably responsible for spread of infec- eral days, and showing very little im- tion when seen in epidemic form. provement, he returned to his home. The majority of observers agree that Two months later he was brought back common house fly is one frequent cause because he was having convulsions epil- of spread of infection, basing their be- cptic-like. Aphasic .symptoms were im- lief on continued prevalence of condition proved to some extent. He could read ~ .„ , , „ ,v, .,r , r. f ^t ,• , ^ „^ 1 •, . , , , , , Read before the Wake County Medical So- and write some simple words and able ciety, May ii, 1922, September, 1922. ORIGINAL COMMUNICATIONS 471 during late summer months when heat be made of exact importance of any ex- is less excessive but flies are more nu- cept Bacillus Dystenteriae. merous. It is also spread by means of Ileo-Colitis seems prone to follow oth- contact with acute cases or carriers by er diseases such as broncho-penumonia, means of food as cow's milk, condensed or to occur in infants who have suffered milk, ice cream, and by water. from chronic intestinal indigestion and Lifectious diarrheas have two syn- its consequent malnutrition. In typical onyms, ileo-colitis and dvsentery, latter cases the infecting organism invade wall term suggests unvarying relationship of the gut early, causing infiltration of to Bacillus Dvsenterv. A large number the mucosa. The inflammation spreads of inquiries have been made in various to sub-mucous layer and involves soli- directions with reference to pre-dispos- tary lymphatic nodules. They later may ing and etiological factors of these dis- break down and ulcerate, resulting m eases, for example, influence of seasonal punched out cavities. In other severe and hygienic conditions, of natural and types the superficial infiltration may be artificial feeding, milk pasteurization, followed by necrosis which leaves irreg- etc ular ulcers. Secondary to lesions of the While recognizing that in infantile bowel we find enlargement and conges- diarrheas many possible factors have to tion of the mesenteric lymph nodes. Dys- be taken into consideration, there exists entery bacilli do not invade the blood a particular virulent tvpe occurring in •'stream except in very rare instances, summer which there is everv reason to ^nd the general symptoms are due to believe has an infectious origin. Esche- toxins. In this way secondary infection rich in Austria and Booker in the United can be explained such as broncho-pneu- States were among earliest observers of "^onia. Since the disease is systemic intestinal flora, but were unable to ob- toxemia as well as local infection, we tain pathogenic organisms of specific "dually find parenchymatous degenera- tvpe in diarrhea stools. In 1898. Shega tion to greater or less extent in liver, isolated B. Dysenteriae in Japan and in l^^ keeps striving, to some degree, enic tieatment in necessity i^^ ^^e ^ ^ ^^ ^^^^ This element of prompt and efficacious management of "" [r . .u o f n„,-,,r.i^o i^ • X X- 1 J i. • -x • function in the Surgery of Cripples is every intestinal derangement in its in- ^ "''^' . , %^ -^ ^^,^^„^ +^ i^ ^.jpjgj^^g the thing we stuQ to preserve, to im- This is further borne out seemingly P^o^'e- or to establisn. by the phenomenon of De Herelle with To get the maximum of weight bear- bacillus dysenteriae, which is expression ing and motor function in the lower ex- of lytic reaction occurring between a tremities of the body, one must interpret bacterium which is inducing an infection * Rg^d before the North Carolina Medical in an animal and a substance elaborated Association, winston-Saiem, April, 1922. 474 SOUTHERN MEDICINE AND SURGERY September, 1922. muscle balance becomes a rather simple formula, a matter to be taken care of by, — development of weakened muscles, transplantation to obtain or alter muscle pull, or the use of braces. 1. K. B. (a) Infantile Paralysis in in- fancy. Pathological torsion of the femur outward. The trochanter is back and the thigh slightly adducted in attemi)t to com- pensate. 2. J. H. (a). Pathological tibia torsion, outward (left). Paralytic Club foot. (In- fantile Paralysis in infancy.) 1. K. B. (b) The femur torsion correct- ed by the operation described. The align- ments of the extremity look more normal. into the skeleton of these extremities, correction in weight lines before expect- ing proper muscle balance and function. After the skeletal lines are established, 2. .J. H. (b). Corrected. The tibia tor- sion was corrected by Osteotomy and ro- tation of lower segment inward. September, 1922. ORIGINAL COMMUNICATIONS 475 In cripples, either emergency or chronic, one of the most frequent dis- abling pathological entities is bone tor- sion. It may be insignificant or it may ^^ 4.. 4. A. L. (a). Pathological tibia torsion (right). Paralytic club foot showing con- tracted heel cord, cavus, hypertrophy of the astragalus and mal-alignment toward outer aspect of mediotarsus. 3. C. R. (a). Pathological tibia torsion outward (right) with associated knock knee and paralytic chih foot. ;>. C. R. (b). Correction of knock knee and tibia torsion by one high tibial osteo- tomy. 4. A. L. (b). Corrected by tibial Osteo- tomy and rotation, sub-astragaloid arthro- desis, sectioning the neck of the astragalus and transplanting the cartilage-free head into corrected alignment. 476 SOUTHERN MEDICINE AND SURGERY September, 1922. 5. B. J. (a). Pathological tibia torsion outward with associated paralytic (infan- tile) flat foot. 5. B. J. (b). Corrected by tibial Osteo- tomy and rotation, inward of lower frag- ment. Subastragaloid arthrodesis and properly aligning the denuded head of the astragulus. be marked — as in some of the cases I will show you. This torsion is brought about by faulty resting positions, or gravity acting at a time when unopposed by normal muscle tone. All have seen it suddenly occur in broken continuity of bone, as in fractures, and we plant to correct it in the treatment of such frac- tures. We are not so much, though, on the lookout for it in chronic conditions, as infantile paralysis, club foot, flat foot, etc., and therefore sometimes fail to fig- ure it into our plan of treatment. When one fails to recognize pathological bone torsion and fails to correct it, funda- mental weight-lines are off, and muscle balance, if corrected, will not hold. This torsion is most noticeably true in the shaft of the femur and tibia follow- ing the more or less neglected cases of infantile paralysis. It begins to occur early. At first it is only slight. Then in a number of months or years it becomes pathological. In acute infantile paraly- sis the muscles of the thigh or leg, or both, are completely paralyzed, the tro- chanter drops backward, the foot rolls out, and added to the weight of a para- lyzed limb are usually the bed covers, and no preventive apparatus. This can start the torsion. Later unequal muscle recovery allows the assumed position to become more exaggerated. Attempted weight-bearing on bad lines throws the plane of the rotated trochanter "off cen- ter" from the plane of its fellows, and unbalances the pelvis. The gait is bad. The perpendicular planes through the center of the knee and ankle are not par- allel. The medial line of the ankle is everted. The heel is inside the posterior knee line. There is usually associated knock knee. The torsion of the tarsus is in the abnormal lines of the astragalus as transmitted to the forefoot. To transplant tendons on top of patho- logical torsion of the skeleton, such as has been described, means poor improve- ment in function, and relapse. Securing proper balance on corrected skeletal lines means improvement and perma- nency. The treatment of cripples is a relative thing. Cures are never made. Improve- ment is the criteria. The motor appa- September, 1922. ORIGINAL COMMUNICATIONS 477 ratus of a normal human being would foot, to the outer, to correct a flat foot, l;e 100'; . The motor apparatus of an deep centrally to correct a cavus or flail untreated cripple is between 0 and 100%. foot. All this is followed by necessary The result of treatment is measured in refining manipulations, tendon trans- per cent of improvement in function. It plantation, massage, exercises and train- is a gain to get from a bed to a chair, ing; description of which themselves, from a chair to upright with braces and w^ould necessarily constitute other treat- crutches, from this to braces or crutches ises. alone, or neither. It is a gain to walk where one has crawled. It is a gain to be on the sole of the feet when life has been spent walking on the sides of one's LEUKOCYTIC REACTIONS TO feet. These are not lOO';; cures. They are improvements. MOKPHIN. When the attempt is made to correct femur torsion (The Femur Turning Op- ^"'"^^^^ ^'^ presented by Chauncey eration of Hoke) the knee is rotated in, ^- ^eake (Journal A. M. A., June 3, held, and the fascia lata is secured taut 1^22), concerning the effect of mor- behind the trochanter. Then the femur P^in on the leukocyte counts in rabbits, is osteotomized in its lower fourth and dogs and men. There is always a rela- the knee faced forward. Below the knee tively sHght leukopenia, lasting for is disregarded at this time. about an hour after the drug, followed When tibia torsion is corrected (The ^^ ^ "^o^e pronounced leukocytosis Tibia Turning Operation of Hoke) a maintained for ten hours or more, and sub-periosteal osteotomy complete is returning to normal within twenty-four done just below the knee and while hold- hours. The differential counts show a ing the knee in line, the tibia is rotated large relative increase in the number inward until the line of the heel is di- of polymorphonuclear neutrophils, with rectly behind the knee. The fore foot is a diminution in the percentage of disregarded at this time. lymphocytes, and relatively insignifi- When the deformities (torsions) of cant changes in the percentage of the the tarsus (club foot, flat foot, flail foot, leukocytic elements. This indicates an calcaneus, cavus, etc.) are attacked the absolute increase in the number of poly- basic change is brought about by first ' morphonuclear neutrophils, the number removing the cartilage from the under of lymphocytes remaining the same. In surface of the astragalus and the upper two dogs a second injection of mor- surface of the os calcis. In the next step phin at the time when the leukocy- the prolonged neck of the astragalus is tosis was marked, four hours after the sectioned, the head of the astragalus is first injection, resulted in a further in- removed from the foot, its cartilage de- crease in the number of white blood nuded, together with the opposing car- cells within an hour without any previ- tilage of the scaphoid, and then the raw ous leukopenia. In estimating the diag- head transplanted back into the tarsus, nostic value of a white blood cell count The new position of this astragalus head after the administration of morphin, determines much of the correction. It is allowance must be made for the effect placed to the inner side to correct a club of the drug on the count. 478 SOUTHERN MEDICINE AND SURGERY September, 1922. comes as tough as the sole of your shoe, SOUTHERN MEDICINE AND SURGERY Te ItronTa^irol bandsTwas'n"? Published Monthly by the Said of one who had not trained. ^w , .... m. ^- . . .^ strength was demanded, and Nature Charlotte Medical Journal Company t j j-l. j. ru i i. i j^j. *^ ' supphed the strength, but only after M. L TOWNSEND. M. D. / the Will had made repeated and insist- J. c. MONTGOMERY, flj. D. ," Editors ^^^ demands— only after years of exer- CHARLOTTE. N. C. ^^^f' , Mental exercise is fully as assential to mental growth and mental strength as "Read not to contradict and confute, nor to jg physical exercise to muscle growth, believe and take for granted, nor to find talk . i -j. • • t- *. j-u i. j-u u and discourse, but to weigh and consider."- Also it IS just as true that the charac- Francis Bacon. ter of the exercise will determine the ^^___^__^_^^___^^_^_______^__ character of the growth. There is a cause for every event and School Days. ^^^^^'^y' ^V""^'^ ""^Ti -^'-^^l" ""^^^Z able bounds every life is just exactly These are vital days. Last week, this what environment and teaching made week and next week the children and '}■ . ^^e proper menta attitude and young people are starting in a new ^^^^"^"^ Y^" ^^^' ^ '^^"^1^^ pick pocket year of school work. During the com- f .f f ^^^ preacher. Finite mind often ing months lives will be moulded either ^^'^^ ^o see the cause or to connect the for good or bad. Habits of good health ^^"«^ with the result but no child ever or bad health as well as habits of think- happened to go bad and you did not ing and doing happen to be a doctor or a preacher, We are especiallv pleased to present 1^^^^^^^ ^'^ ^^/^ brother happen to be a in this issue a number of Public Health '^^J.?,^ °^ % u^,"J^^' u • • Papers and we are very anxious to en- ^^"^o"^ ^^ ^^ildren are now beginning courage the wholehearted co-operation a school year which will determine their of the medical profession with the coun- ^^^"^^ usefulness to themselves and the try's teachers to the end th.t the com- '^"TT^J ^" ^^^^^^^^^^ 1^^^- \^:^,^ ing generation may be physically strong- ^ght of these facts, then, are your child- er and healthier as well as being better i;^" "°^, J^^l^ ui'Ti''" Z . educated in the common acceptance of ^e? In the light of these facts are you that term doing all you can do to make your school Good health goes hand in hand with J^^^ ^^at it ought to be? education and the school that does not inculcate in the children the fundamen- The College Student and Venereal tals of health conservation should be Disease. renovated from cellar to attic. The two fundamental, biological laws (Excerpts from Public Health Reports.) of all nature are self preservation and Is venereal infection decreasing the perpetuation of the species. The among college students? Rather defi- degree of education is measured, or nite answers to this query came as an should be me.^sured by the individual interesting sidelight to a recent effort on ability to fight life's battles and meet the part of the United States Bureau and solve life's problems. Our effort of Education and the United States Pub- then is to develop strong minds in lie Health Service to obtain from college strong bodies, that the individual may presidents their opinions with respect be preserved and the species perpet- to the prevailing attitudes and practices uated. of college men in the matter of sex. Nature is extremely accommodating Nearly one hundred college and univer- and the lilly white hand that repeatedly sity executives were asked the following picks up the hammer handle soon be- questions: September, 1922. EDITORIAL 479 In your experience does it seem that change. loosely classified, are, first, edu- Ihe student's attitude toward sexual cation, both popular and academic, in promiscuity, or his habits and practices matters of health, with an increasing have undergone any consideable change emphasis on the hygiene of sex and ven- during the past fifteen years? If so, ereal diseases; second, a more active what is the direction of the change and concern on the part of the college in the to what forces do you attribute it?" physical well-being of its students, in- In all, 65 replies were received, em- eluding increased opportunities for phy- bracing comments on a variety of mat- sical training and play activity ;third, ters such as the apparent growing fami- improvements in environmental factors, liarity between the sexes, the effect of such as the elimination of the saloon the war and contact with European and the suppression of prostitution, and, standards upon sex conduct, the prevail- fourth, the influence of co-education up- ing fashions in dress, the modern dance on the "atmosphere" of the college, forms, the conversational habits of The criterion chiefly relied upon in students, and the prevalence of venereal support of the belief that college stu- diseases and the attitude of college men dents today are living a cleaner and toward them. These various problems healthier sex life than heretofore is the of conduct, directly or remotely related evident decline of venereal infection to sex, are discussed, as might be ex- among this particular group, pected, from many points of view. What A few typical quotations from various one president sees as a sign of relaxed representative colleges and universities moral standards, another views simply follow: as a symptom of an eff"ort to place sex "A physician in this town who has relations on an intelligent and enlight- much to do with the college students as- ened basis. The effect of the war comes sured me that there was far less ven- in for a good deal of discussion, with ereal disease today than 25 years ago." some diversity of opinion as to its ulti- "In our examination of 3,500 or 4,000 mate effect upon sex standards. On one boys each half year, we do not see more topic alone is there unanimity of opin- than three or four cases of acute vener- ion — that of venereal diseases. The fact eal disease a year." that practically forty per cent of the "One fact on which I count heavily replies specifically mention venereal dis- is that the college physician steadily re- eases signifies the importance attached ports to me that cases of venereal dis- to them by college presidents. eases in the student body have become The college student of today realizes extremely rare, and he is in a position to more fully than his brother of an earlier speak with some definiteness -on the day the dangers and severe risks to subject." health involved in promiscuous sex re- "Although the number of students is lations and as a consequence is much constantly increasing, this particular more circumspect in his conduct and has form of student vice has shown a con- on the whole a more enlightened atti- stant decrease. This I have not only tude toward all sex matters. Such at from my own observation, but from the least is the concensus of opinion among reports of the physicians and hospitals college presidents. That this change in the city." in attitude and practice is not due al- "In this college at least there has been together to a higher "sense of morality" marked improvement during the last is frankly conceded by a number of decade or two. There is little to support presidents, and there are a few who my general impression except that the seem to regret that "hygiene" rather results of our physical examination of than "morals" has been the dominant the men students are highly satisfac- motive in the change that appears to tory." have taken place in the past fifteen or "One thing I am certain of, is, that twenty years. there has been a marked decrease in The forces responsible for this sexual diseases among college students ^^^ SOUTHERN MEDICINE AND SURGERY September, 1922. f'uring recent years. This has been dis- A few of the presidents state that ven- tinctly noticeable. At the University of ^-nl diseases hive always been neg- last year more than 7,000 jigible among their students, but the students were registered and there were testimony of the large majority, of not more than 20 cises at any one time, those who consider the matter, is that This improvement is due chiefly to edu- the last few years have witnessed a sub- cation. Students are learning more and stantial and, in some instance, a very more the danger of sexual diseases and marked decrease in the number of ven- as a consequence are avoiding them." ereal cases. It would not, of course, be "My impression is that there has been in keeping with scientific accuracy to a marked reduction in sexual promis- contend that the opinions set forth have cuity and practice during the past fif- the potency of facts. In but few in- teen years and I believe this is chiefly stances have conditions in colleges or due to the better understanding by boys elsewhere been statistically verified, and girls of the relationship and the The latest group thus far subjected to rights of a socially just conduct between examination was the second million them. The specific evidence I refer to is drafted men. Examinations at mobili- the record of medical examination and zation camps showed that 5.6 per cent supervision of student body at of these men had a venereal disease at in the year 1919-20. We discovered only the time of examination upon arrival at one history of syphilis and one of camp. This percentage includes only gonorrhea in original examinations and obvious cases of syphilis, gonorrhea, and a total of 10 cases (8 gonorrhea and 2 chancroid. Wassermann examinations syphilis) during the year in the entire were not given. Furthermore, this per- student body. From records of previ- centage does not include those who had ous years it was evident that this con- been cured prior to the day of examina- stituted a very great reduction as com- tion or who may have become infected pared with pre-war conditions." later. Assuming, however, that 5.6 per "During my time here I have found cent fairly represents the percentage of only two cases of venereal disease in venereal diseases among unselected this college, and, we give all students groups of the population at any one medical examination. It appsars to me time, it is obvious that the rate among that there must have been great im- college students, judging tentatively by provement along this line." the evidence at hand, is decidedly lower. "I feel absolutely certain that the con- • ditions of the college, as far as the at- Medical Education. titudes and practices of the undergradu- ates are concerned, were never so good. North Carolina is face to face with a This f-ct is borne out and largely prov- big problem. There are people in the ed, I tnink, by the data in regard to state who are not getting proper and venereal disease, the figures concerning suff"icient medical care and North Car- which are always available to us. The olina considers the establishment of a proportion of men in college at the pres- complete medical school of A grade ent time so afflicted is an almost neg- where her own sons and daughters may ligible quantity so far as per cent goes, receive a finished medical education, as against con:.itions in my own time in The need for such a school is so ob- college when there was hardly any vious that there remains no argument, group within the college in which there provided it is a school that will serve would not be found men so afflicted." the purpose and supply North Carolina's In view of these opinions, may the need, question, "Is venereal disease decreasing This is a question the state needs among college students?" be answered to consider most carefully— and to do in the affirmative? More than 20 col- this logically we must begin at the be- lege presidents say "yes," and not one ginning and let our reasoning follow out is found expressing a contrary opinion, in logical sequence. I September, 1922. ' 1 ~^ I EDITORIAL " ~" 481 The Need. while in 1920 there was scarcely a fam- The State is a densely populated rural ily in the entire State that could not state with no large cities— no large cen- have easy access to some neighbors tel- ler—but a fairly equal distribution of ephone. There was hardly a doctor in population throughout the State. It is the State without an automobile and therefore perfectly obvious that this very few places where in the worst win- rural or small town population can not ter weather he could not drive his car be cared for by "metropolitan" doctors, to the patient's door. Taking these facts If this rural population receives medi- into consideration it would easily seem cal care for their minor ills it must be that in 1920 one doctor could more effi- by doctors who go and live where the ciently and more comfortably care for people are. It is also perfectly obvious 2,000 people than he could care for 1,087 that the super trained specialist and re- in 1890. search worker will not be content with This most emphatically compels us a rural practice, and neither would his to say that if we consider census reports metropolitan mental attitude and habits only then the State is better able to be welcome in the ordinary mill village care for its sick now than ever in its or farming community. The successful history. This assurance, however, does doctor does not live who, regardless of not prevent thousands of people in cities, his natural ability and qualifications, villages and the country from asking the does not adapt himself to his environ- question repeatedly, "Where can I get a ment and the station of his clientele. doctor who will come to my home?" North Carolina has perfectly splendid Neither does it prevent this journal doctors, men who are up to the minute from receiving many letters from good in all medical matters, well trained and locations asking that we help them find efficient. North Carolina is well sup- a doctor who will locate with them. plied with specialists and research Even in the cities where the supply of workers, sufficient to supply her every doctors is greatest there is the uni- need, but she is poorly supplied with versal complaint that it is so hard to men who will roll up their sleeves and find any doctor who will answer house do for her people the things her people calls. want done and need to have done at Why then this anomalous situation of home. This statement is made with water, water everywhere and not a drop reference to North Carolina but the to drink? There is no actual shortage same is also true of every nook and in numbers but for several years no corner of this entire United States. The young man has been allowed to enter need is not for specialists and research the profession until he had become, in workers but for broad minded general mental attitude and long years of college men qualified and willing to care for training, a specialist. North Carolina's people where North The Remedy. Carolina people live. Having, then, recognized the illness, The Cause. and decided on the diagnosis we must In 1890 the State had one doctor for next seek a cure, every 1,087 people and no one complain- We must not discourage specialists. ed of being unable to get a doctor when We must encourage in every possible needed. In 1920 the State had one doc- way every advance in medicine. There tor for every 1,144 people which shows must be no lowering of medical stand- an actual proportionate increase of pop- ards, and every man should be encour- ulation over the increase of doctors— on aged to develop the talent that is within the other hand, however, we must not him. But the system of medical edu- fail to recall the difference in conditions cation which has only one kind of between 1890 and 1920. In 1890 there product in view is narrow, bigoted and were no automobiles and no rural tele- blind. It is perfectly absurd to try to phones and we can also say that during "make a silk purse out of a sow's ear" the winter there were no passable roads, and equally absurd to try to make a 482 SOUTHERN MEDICINE AND SURGERY September, 1922. sow's ear out of a silk purse. financial backing sufficient to carry on And right here is the tender spot — super scientific research in competition right here is the cause of the whole with institutions elsewhere already es- trouble. There are multitudes and mul- tablished and North Carolina does not titudes of men who had the proper men- need such an institution if she could tal attitude to live happily and content- get it. Indeed if North Carolina is try- edly with their brothers and cousins and ing to establish a medical teaching in- who had abundant natural qualifications stitution which will ape this kind of to live most useful lives in their com- school she is better off with no school munities doing for their kith and kin at all. Such a school would not only the things needed and with sense enough not meet North Carolinas' needs and re- to know their limitations and refer to lieve the present situation but would in others the extreme and complicated fact aggravate it and not only waste cases, but whose maximum usefulness the money but would make bad matters has been curtailed by a system that has worse. given them a false mental attitude and North Carolina needs a sensible, prac- made them try to do the things they tical medical school of A grade where never can successfully do. Multitudes sensible, practical men may be efficient- of perfectly splendid doctors have been ly prepared to meet the country's need ruined to make poor, and often danger- and care for the country's sick people ous, specialists. where these sick people are. And to The situation must be met as it is and illustrate all other rarely needed re- not as it might be and the fact is that fined methods of diagnosis such a as valuable as the electro cardiograph is school needs an electro cardiograph not one man skilled in its use can easily do to teach technique but to demonstrate all of that kind of examination that its usefulness in indicated cases so that would be indicated in the total combined the student in practice will refer his clientele of 500 doctors. And so with any thousandth case to the man skilled in specialty whatever it may be one its use. specialist can do the work for many doc- tors— and very candidly you know that Medical School Committee. it is only a small percentage of the At the request of the University Com- help the people are askmg for that mittee and Governor Morrison, Dr. J. needs to be refered to a specialist at w. Long, President of the North Car- ^"- olina Medical Society, has appointed a Then it is obviously true that for committee of 30 from the State Medical every teaching institution turning out Society to cooperate with other agencies specialists there should be many teach- jn the matter of considering and making mg the fundamentals of medicine and recommendations as to the establish- turnmg out practical clinical doctors, ment in North Carolina of a full four- To maintain an advanced super scien- year Diploma Granting School, tific teaching institution requires un- Following is the personnel of the corn- told wealth and the United States is mittee: most fortunate in having scientific Dr. I. W. Faison, Charlotte, Chairman, foundations and heavily endowed insti- Dj. a. J. Crowell Charlotte, tutions amply meeting this need. With Dr. J.' T. J. Battle, Greensboro. Rockefeller, Carnegie, Harvard, Hop- Dr. J. H. Shuford, Hickory, kins, Columbia and a host of others, Dr. C. M. Van Poole, Salisbury, there is plenty of room for the man Dr. E. J. Dickinson, Wilson, whose practical experience has proven Dr. L. B. McBrayer, Sanatorium. his knowledge of the fundamentals and Dr. W. L. Dunn Asheville. his natural ability — to take advanced Dr. H. H. Briggs, Asheville. study and to specialize. Dr. D. T. Tayloe! Washington. North Carolina can not hope to have Dr. J. F. Highsmith, Fayetteville. a teaching institution with unlimited Dr. J. W. McGougan, Fayetteville. September, 1922. EDITORIAL 483 Dr, Foy Roberson, Durham. Dr. Fred Hane.s, Winston-Salem. Dr. W. B. Holt, Duke. Dr. J. H. Way, Waynesville. Dr. Cyrus Thompson, Jacksonville. Dr. E. J. Wood, Wilmington. Dr. E. M. Mclver, Jonesboro. Dr. W. F. Hargrove, Kinston. Dr. C. O'H. Laughinghouse, Green- ville. Dr. I. P. Battle, Rocky Mount. Dr. T. E. Anderson, Statesville. Dr. A. C. Everett, Rockingham. Dr. Peter John, Laurinburg. Dr. W. H. Cobb, Goldsboro. Dr. R. H. Lewis, Raleigh. Dr. W. S. Rankin, Raleigh. Dr. Hubert Royster, Raleigh. The University committee consists of: Mr. W. N. Everett. Mr. Edgar W. Pharr. Mr. H. P. Grier. Mr. J. J. DeLaney. Dr. I. H. Manning. Dr. W. de B. McNider. This is a body of strong men, each possessing keen business judgment and they are not going into this matter to be swayed by any sentiment or emotion but to consider all the facts in their im- partial relation and to have first and al- ways in mind the everlasting best good of the State of North Carolina. This State has its own individuality and its own peculiar problems to solve. Just as there are no two sick people although suffering from the same dis- ease who can be treated exactly alike, so there are no two states who can follow exactly the same regime and expect the greatest benefits. North Carolina is not a state separate and apart from all other States with problems so entirely different but never- theless North Carolina's problem is pe- culiarly her own. This large committee will first study North Carolina's need and find out just exactly what it is that North Carolina wants and then, and certainly not until then, will the committee in the light of experience of other states, devote itself to devising the best way to meet North Carolina's need and solve North Caro- linas' problem. This committee has too much sense to put the cart before the horse. They will first decide if the State needs more doctors, and if she does what kind of doctors, whether practitioners or re- search workers, and if a school is need- ed to produce specialists and research workers the committee will submit ap- propriate recommendations — and if a school to prepare doctors to live with and care for North Carolina's rural and small town population the committee will submit different and appropriate recommendations. After deciding the needs of the State and the kind of school es.sential to supply that need this com- committee may look about to see where that special type of school could best be located to be most efficient. This committee is not going to recommend arbitrarily establishing a medical school on the University cam- pus or at Wilmington or Asheville, or Charlotte, to turn out a certain kind of product and then expect the people of the State to conform their needs to meet the supply. MEDICINE Will. D. Porter, M.D., Dept. Editor Syphilis of the Bronchi and Lungs. Balzer (Paris Med., January 21st, 1922) states that modern methods of investigation have shown that syphilitic affection of the respiratory system is more frequent than was formerly sup- posed. Tertiary tracheo - bronchitits leading to ulceration and stenosis has long been known, but it is only within the last few years that chronic bron- chitis with emphysema of the bases and more or less bronchial dilation has been described in the secondary and tertiary stages. The symptoms are dyspnoea and paroxysmal cough. The dyspnoea is often of long standing, and may even date from childhood. It is increased by effort and gives rise to attacks at night resembling asthma. There is little or no fever. There may be impairment of resonance at the apices, with harsh inspiration, prolonged expiration, and diffuse, bronchitic rales. The sputum 484 SOUTHERN MEDICINE AND SURGERY September, 1922. does not contain tubercle bacilli. In Dietetic Treatment of Chronic Arthritis syphilis, as in tuberculosis the specific and Its Relations to Sugar Tolerance. inflammation is centred in the bronchi. Fletchers, Arch., Int., Med., 1922, Vol. This explains why bronchial dilation is 30, 106, reports the result of the dietetic observed in a variable degree in most treatment of 100 cases of chronic ar- cases of pulmonary syphilis. In con- thritis. Most of the cases treated were genital syphilis the lung may be af- of the periartiarlar types ; a few hyper- fected as early as the third, fifth, or trophic bone changes. The dietetic sixth months. At a later stage it is ob- treatment was started at least six weeks served between 3 and 15 years, and even after the onset of the joint pathology, between 15 and 20 (Castex and Queirel). The diet used routinely consisted of Cases of pulmonary hereditary syphilis three glasses of milk, three glasses of have been seen as late as 34 or even 40 buttermilk, one half grape fruit, and years (Lancereaux). In the child, as one or two oranges a day for one week, in the adult, pulmonary hereditary Then the gradual addition of such foods syphilis sometimes presents a latent as eggs, fish, foul, meat, 5, 10, 15 per prodromal stage, which is sometimes cent, vegetables, fruits, junkets, jellies, very long, in which the only noticeable and finally brown bread in small feature is impairment of the general amounts. Patients who were under condition and tendency to bronchitis, weight were allowed Cod Liver Oil, and Cough with muco-purulent expectora- cream. The increase in food was made tion, chiefly at night, is observed. The so as to provide 1,500 to 2,000 calories dyspnoea, which also occurs at night, is a day within four weeks time, aggravated by effort and becomes per- Of the hundred patients treated eight manent. The patient may suffer from recovered, forty-three were much im- vague pain in the back, perhaps due to proved, twenty-eight improved, and pleural lesions. The usual site of the twenty-one showed no improvement, lesion is at the base or hilum of the No other form of therapy was resort- right lung, and sometimes at both ed to except rest and laxatives as indi- bases and apices. In an advanced stage cated. It can be noted that the diet con- bronchiectasis almost always occurs sisted of a minimum carbohydrate con- which is more or less localized in the tent and a very low total caloric intake, bronchi of a pulmonary lobe. (1.) Cir- Many of the cases showed a low sugar cumscribed gummatous or sclero-gum- tolerance, but there was no relation be- matous pulmonary syphilis, which may tween this and severity of the disease, be associated with pleiral or glandular The author draws the following con- lesions. (2) Diffuse pulmonary sphilis elusions: (1.) "Of one hundred cases of or subacute or chronic bronchopneumo- chronic arthritis reduction of diet ap- nia. (3) Rarer varieties resembling the peared to result in the recovery of eight, pnuemonia of the newborn. (4.) Brown and quite evident improvement of induration. (5.) Bronchial and medias- forty-three. (2.) "The sugar tolerance final adenopathy associated with pul- was decreased in the large majority of monary syphilis. The principal anto- these cases and this decrease showed .,,.,.,. , , , no relationship to the severity of the mical distinction between pulmonary ^.^^^^^ ^3^ "Patients who have low syphilis and tuberculosis is that m tolerance are much more frequently tuberculosis all the three coats of the benefitted by reduction in diet than those arteries are attacked, while in syphilis cases with a normal tolerance. (4.) "In the tunica media resists for a long time certain cases of chronic arthritis dietetic and may escape altogether. The process regulation appears to be the most ef- . ^ ^ .^ , , -i-f. 1 XT J fective form of treatment, and while the 13 definitely syphilitic when the adven- ^^j^^ ^^ ^^^^ treatment in an individual titia presents groups of plasma cells, ^^se cannot be determined with cer- newly formed capillaries, and elastic tainty, the lowering of the sugar toler- fibres, ance is a useful clinical indication for SURGERY A. E. Baker, M. D., Dept. Editor September, 1922. EDITORIAL 485 this procedure. (5.) "Female patients these factors back to normal, derive greater benefit from such treat- Cases of gastro-intestinal disorders men than the men, and, as a rule they which have been unable to take sufficient show a lower tolerance." food for long periods are very apt to have a starvation acidosis. When this Osier. The evolution of Modern condition is found to exist, by previous Medicine — Osteo arthrtis appears to blood chemical tests, a two-stage opera- have been most prevalent among the tion may well be considered as being of ancient Egyptians. This has been a distinct advantage to the patient, studied by Rupper and others. "It is in- In the last few years our attention teresting to note that the 'determina- has been called to the importance of tive' of old age in hieroglyphic writing pathological physiology. It does not is the picture of a man afflicted with matter so much whether an organ is arthritis deformans." diseased. The point to be determined is. what is the functional capacity of the diseased organ in question. The func- tional tests of the various organs or systems are of great importance in estimating the physiological state of the ^ ' patient. A poorly functioning organ is A most interesting and profitable to be feared more as a factor bearing paper, "The Value of Blood Chemistry on the "operative risk" in a patient than to the ^Burgeon," by Dr. Wm. H. Bailey, a diseased organ that is doing its work Southern Medical Journal, May, 1922. satisfactorily. I may add the internist is equally in- Just as a chronic heart condition will terested in its value in the diagnosis, sooner or later nearly always secondar- treatment, and prognosis of patholo- ily affect the function of the kidneys, so gical conditions. Many unsolved prob- also the deficiencies of many of the meta- lems in medicine of today will find their bolic processes of the body will ultimate- solution in blood chemistry ; for instance, ly lower the function of the kidneys, many surgical deaths following opera- We must investigate not only the ability tion for septic conditions should be re- of the kidneys to excrete normal and ported as due to acidosis rather than abnormal substances but we must find some other cause. An individual can- out by blood chemical tests what sub- not live unless the blood is alkaline. This stances, especially of the non-protein alkaline balance has been shown by nitrogen of the blood they are not ex- Henderson to be maintained by certain creting. It is supposed that it is the buffer salts in the blood. The degree of retention of these element that is harm- alkalinity of the blood is represented by ful to the patient. its H-ion concentration and the carbon The surgeon has been quick to take dioxid combining power of the blood advantage of the assistance that the plasma. When the H-ion concentration routine blood counts, urinalyses, and of the blood is lowered even a very little other laboratory tests can give him in the blood is unable to carry the carbon the working out of diseased conditions, dioxid to the lungs, the normal equili- Without lessening his efforts to make a brium is lost and acidosis begins. diagnosis of the pathological lesion in Ether anaesthesia has been shown to his patient, the surgeon must also make produce an acidosis, so that if a previous a careful study to determine the func- chemical examination shows the H-ion tional ability of his various organs. He concentration to be low or the eombin- must accurately estimate his resistance, ing power of the blood plasma for carbon his vitality, his physiological state ; in dioxid to be lessened, ether should not other words, his "operative risk." It is be the anaesthetic selected. If ether has ths special point which the surgeon alone to be used, preoperative treatment of must decide. It is in assisting him to the patient should be given to bring decide this special point that blood 4S6 SOUTHERN MEDICINE AND SURGERY September, 1922. chemistry is of its greatest value to the be left to some one not thoroughly con- surgeon, versant with the chemical procedures in- When we reach the stage of the prog- solved, ress of surgery where all surgeons care- The estimation of blood creatinin is fully work out the surgical risk of every the most valuable prognostic sign we case by accurate clinical and laboratory have in cases of renal deficiency, methods before operation, we shall have Blood chemistry is of special value in reached what Frank has aply termed "an cases of hypertrophied prostate and epoch of physiological surgery." Conclusions The glucose tolerance test has been shown to be of considerable assistance in establishing the diagnosis of cancer, other mechanical chronic obstruction to the out-flow of urine. We should strive to attain that ideal, when every operative patient will be carefully studied by clinical and labora- especially of gastro-intestinal carcinoma tory methods to accurately ascertain his when the other conditions that give a similar blood sugar curve have been eliminated. Ether should not be the anaesthetic of choice when the patient is found to show an acidosis by a low carbon dioxid com- bining power of his blood plasma, or some other of the accepted methods. In gastro-intestinal cases showing a starvation acidosis a 2-stage operation may well be considered. A poorly functioning organ is to be "surgical risk" before operation, as then that epoch of "physiological surgery' will become an established fact. Gynecology and Obstetrics Robert E. Seibels, M. D., Dept. Editor Pregnancy and Heart Disease: This subject is considered by Herrick (Am J. obst, and gynes. 1922 IV. 1-18) in a feared more as a factor bearing on the review of forty cases at the Sloane Hos- operative risk of the patient than a dis- pital for Women, New York. He em- eased organ that is doing its own work phasizes the point that the heart of the satisfactorily, patient is the center of interest in the Many efficient metabolic processes of management of the case, for "no matter the body may ultimately affect the func- how skillfully labor be guided, it is the tioning ability of the kidneys. tardy recognition and care of the heart No one test for kidney function should which is responsible for the high mor- be used to the exclusion of all others. tality." It is certainly true that one Blood chemical tests, like all other is apt to view the problem as an obste- laboratory procedures, must be consid- trie one— how shall labor be terminated ? ered only as additional clinical evidence —rather than as a combined one of in- and their value determined by weighing creasing the cardiac compensation and them with all the data available. reducing the second stage to the mini- A phenolsulphonephthalein of P-S-P mum. test output of over 75 per cent in two Whether or not an abortion is to be hours may be a sign of lessened kidney performed early in the pregnancy de- function, pends on several factors. In a primi- A low P-S-P result is not always an para one must consider the cardiac re- indication of a serious kidney impair- serve and the compensation rather than ment, especially when the blood reten- the name of the lesion. Under adequate tion products are not found to be exces- care, cardiac lesions seem to go through sively high. a pregnancy with remarkably little per- A high blood urea content is probably manent damage. In a multipara, the always an indication of lessened kidney action of the heart in previous pregnan- function regardless of the results of the cies is a guide to what may be expected other test. of it under the present one. That there Satisfactory results cannot be expect- is danger of increasing the lesion or ed from these tests if their performance decreasing the reserve should be ex- September, 1922. EDITORIAL 487 Urology Crowell, M. D., Dept. Editor plained to the family and their wishes short second stage must be decided for taken into consideration. When an ob- each case. ortion is contemplated in a multipara After labor, a longer period in bed because of previous damaging pregnan- than usual is to be advised. Massage cies, or m a primipara with an advanced and passive movements are begun lesion, sterilization should be considered promptly. Exercise is the simplest and also. This applies especially to the one of the best tests of capacity of the poorer class of patients who can't or myocardium. "If a given effort does won't take the measures necessary to not result in an acceleration of the prevent conception. pulse of more than twenty beats per Herrick urges the treatment of the minute, and if, after two minutes, the case, from the cardiac standpoint, be- rate returns to within five or ten beats fore, during and after labor. of the previous resting rate, the bounds Before labor, rest is indicated, of of cardiac capacity have probably not course. In bed unless she is more com- been passed." Digitalis should be con- fortable sitting up. Minor activity, tinued during the convalescent period, massage and passive motion are useful The tendency to gain weight exhibited to prevent venous stasis. The diet should by post partum cases must be kept in be a light well balanced ration with the nii»cl in cardiacs and prevented by judi- fluids restricted to forty-eight ounces, cious diet, exercise and perhaps thyroid When there is edema and stasis the extract. Karrell method of a quart of milk in ^ twenty-four hours with absolutely no other food or drink, is excellent and may be used for from two to five successive days until results are reached. The sale intake would be restricted. lie uses the standardized tincture of digitalis , ^^'- "• W- E. Wa ther, of New Gr- and gives it until results are received leans, in a paper read before the Urolo- and then reduce the dosage. For ex- ?^^^^ Section of the American Medical ample, in a case presenting onlv slight ^'-'^^''^^^J?,,^^ ^*- Louis and printed m signs of decompensation, 15 to 20 August 26th number of the Journal minims of the standadized tincture are fb'^cussed very ably the Intravesical administered three or four times a day Management of Obstructions in theUre- until the pulse rate is lowered. The ter with Special Reference to Stone and pulse deficit (the diff-erence in the rate Stricture. In a series of 118 cases of as heard at the apex and the pulse beats "J-'eteral stone occurring in his practice, in the radial arterv) is lessened, im- the stones were removed by cystoscopic provement in the subjective symptoms manipulation in 105 cases (88.9 per and diuresis is established. Then the ^^nt) and he believes that 90 per cent dosage is cut to twenty minims every of them at least can be removed by this twentv-four hours which has been "method. Our success in 140 cases has shown to be sufficient in the individual been even greater than this, of average weight when once digitili- His experience m his work coincides zation has been secured. ^^'ith ours as to the usual location of the ' During labor, the obstetrician's nrob- ^tone. namely, " (a) at the uretero- lem is to minimize the effort of the sec- Pelvic juncture, (b) where the ureter ond stage for it is upon its management crosses the iliac vessels at the brim of that depends the future of the myocar- the bony pelvis, and, (c) at the uretero dium. Cesarean section has advocates ^'^sicle juncture. This is practically , ^u 1 ^ f ^x. .the experience of all urologists, there- who urge the advtange of the opportun- ^^^^^ ^^^ ^^^^^^^ ^^^^ ^^^ ^^ j^^j^^^ ity to perform sterilization as well as upon as a piece piping or thought of and obviate pain, effort and strain. The treated as one whose lumen is of the means of accomplishing the end of a same calibre throughout. 488 SOUTHERN MEDICINE AND SURGERY September, 1922. We also agree with Dr. Walther in that tions and dilatations at the points of dilatation is more valuable than ure- most frequent stone impaction like those teral anesthesia, and the installation of mentioned by the writer do not produce oil and normal saline. Ureteral anes- marked abdominal pain such as is ex- thesia is valuable in preventing spas- perienced in a case where the ureter is modic contraction of the ureter during markedly dilated above a given point as the manipulation necessary to get cathe- the result of external pressure or a pre- ter by the stone. It is also wise to anes- viously impacted stone.) thetize it thoroughly before withdraw- Conclusion. ing the retention catheter. He also em- 1- "Many cases of obscure intra-ab- phasizes the importance of lubricating dominal pain are due to obstructions in the stone an ureter thorougly through the ureter. Cystoscopy and ureteral the ureteral catheter. sounding should be employed in all cases Our experience coincides with his in in which the symptoms of abdominal that the removal of a stone from the distress cannot be traced to some defi- lower end of the ureter may be greatly nite surgical condition distinct from the hastened by grasping the stone through urinary tract." the rectum or vagina and manipulating 2. "Stone and stricture are the two it while the catheter is being withdrawn, principal factors in the causation of We heartily agree with the author ureteral onstruction." in the belief that many cases of abdom- 3. "Approximately 90 per cent of ure- nal pain are produced by ureteritis. This teral stones can be removed by non- condition is often overlooked and yet is operative means. Transurethral instru- one which is responsible for many cases mental ureteral dilatation is rational, is of abdominal pain. We disagree with safe in the hands of the experienced, and him, however, in regard to the frequen- is efficient in its results, cy of ureteral stricture. The narrow- 4 -Ureteral stricture is a definite mgs of the ureter's lumen mentioned in finical entity and merits more careful this paper at which points stones are consideration, especially in dealing with most frequently located, frequently mis- abdominal pain in women. Thorough taken for strictures and especially if dilatation produces definite and appar- diagnosed by the use of the bulb. These g^^^jy lasting benefit," narrowings will certainly cause a "pull" especially if there be some congestion or ureteritis. It is in just such cases that one or two ureteral catheterizations often relieve the abdominal pain, yet no one could justly claim that an organic stricture could be cured by the passage in Janarv, 1921, Dr. George H. of a catheter two or three times. Kirby, who is Director of the New York We again agree with the writer in State Psychiatric Ins'titute, and Pro- that we can no longer question the oc- fessor of Psychiatry in Cornell Univer- currence of ureteral stricture but, com- sity Medical College, read before the paratively spreaking, they are rare and New York Neurological Society a paper occur usually in connection with renal entitled: "Alcohol and Syphilis as tuberculosis or as result of ulcertion at causes of mental disease." The con- the site of stone impaction. A chronic tribution appeared in the Journal of the pyelitis has a tendency to dilate and American Medical Association, April elongate the ureter instead. He well 16, 1921, and it is now before this De- s'ays that ureteral stricture cannot be partment Editor in the form of a fiftee.'i- diagnosed by passing a No. 6 catheter, page reprint, every line of which is We believe the plain ureteral catheter worth careful reading. Kirby has ac- and the ureteropyelogram are the best cess to statistical figures on a large sca'e methods of diagnosing pathological con- which enables him at once to get down ditions of the ureter. (Slight constric- to brass tacks in the discussion of al- Mental and Nervous James K. Hall, M. D., Dept. Editor September, 1922. EDITORIAL 4«9 coholic exceses and syphilitic infection number 561, or 10.7 per cent, were suf- as contributing factors in the produc- fering from a mental disease caused by tion of mental diseases. He has been alcohol. In 1920, the total admisisons able to make use of all the statistical to these New York Hospitals had crept information of all the thirteen insane up to 6,573, but of this number only asylums within New York state. Kirby 122 exhibited the type of mental dis- calls attention to the long-believed sta'e- eass that could be attributed to alcohol, ment that excessive alcoholic indulgence In other words, the alcoholic mental dis- and chronic syphilitic infection togeth- orders had declined from 10.7 per cent er are responsible for 20-odd per cent of in 1909, to 1.8 per cent in 1920. Kirby all cases of so-called insanity. is of the opinion that the decrease in He makes use also of the Bellevue the number of cases of alcoholic insan- Hospital figures. In 1910, for instance, ity could not be due to any change in more than 81 per cent of all cases treat- diagnostic method or nomenclature, ed in Bellevue Hospital were diagnosti- The total number of admissions to the cated as alcoholism. In that year the New York State Hospitals has indeed total number of alcoholic patients treat- lessened in proportion to the general ed in that hospital was 10,691 ; but by population. This decrease in the inci- 1920 the total annual number of cases dence of insanity Kirby thinks may pos- of alcoholism had fallen to 2,001, or sibly be attributable to increasing so- only a little more than 8 per cent of the briety of the people, total number of annual admissions to In regard to syphilis as a cause of the hospital. Never before in the his- mental disorder Kirby wonders if the tory of that great institution had it more early and the more certain diag- treated in one year so small a number nosis of the disease, with the improve- of patients suffering from alcoholism, ment in the therapeutic attack, and the The decline in the number of admissions more widely diffused knowledge of the of alcoholism was progressive from scourge amongst lay people, have tended 1910 to 1916-1917, when there was a to make it a more infrequent cause of sharp increase of more than 3 per cent, mental disability. Then again he cites This increase was practically coinciden- figures collected from the State Hos- tal with the entrance of the United pitals in New York state. In 1909, ac- States into the European war, and to the cording to his statistics, 12.6 per cent emotional upheaval and general tense- of all the insane cases in the State Hos- ness of the situation the writer attri- pitals of New York state were due to butes the increase. Since the war, how- syphilitic infection. In 1920, however, ever, the decline has again been steady syphilitic infection still accounted for and progressive. These figures are made more than 12 per cent of all the insane to appeal all the more surprising and in the Empire state, remarkable when one bears in mind the ^ie concludes, therefore, that in New fact that in the 10-year period from york State alcoholism and so-called al- 1910 to 1920 the population of New coholic insanity have declined remark- York city, from which Bellevue draws ^^^^ within the past 10 years. In spite its patients, must have increased enor- ^^ ^^le discovery of the parasitic cause mously. The above figures deal only ^^ syphilis; in spite of the established with the condition known as drunken- j-eiationship of the infection to certain ness, and in them are not included post- ^.^p^^ ^f mental disease; and in spite alcoholic forms of insanity. ^^ ^^le introduction of the newer arsen- Data brought together from the 13 j^^j forms of treatment of the infection, State Hospitals of New York state together with more certain methods of throw light on the problem of excessive ,• jg and more wide-spread knowl- alcoholic indulgence as a cause of in- ^ „ ,' ,. u 4-u i •<- „v.u;i,v. sanity. In lio9. for instance, there edge of the disease by the laity, syphils were 5,222 first admissions to all these still retains practically unchanged its New York State Hospitals: of this age-long dominance as the underlying 490 SOUTHERN MEDICINE AND SURGERY September, 1922 physical basis of the most hopeless form therapeutic reservoir from which it is of insanity. hoped that medicinal substances may be Kirby's contribution is cheering to diffused into diseased brain and menin- the prohibitionist, but uncomforting to geal tissue; if it be not a transudate the syphilographer. Most of the read- there is little hope that medicinal sub- ers of this Journal know that Dr. George stances transported by the blood may H. Kirby's father was for a considerable And their way into it. period of time a number of years ago Research workers will render a genu- superintendent of the State Hospital, ine service to medicine in determining Raleigh, North Carolina. beyond a doubt the unknown features of this strange fluid. The Journal of the American Medi- cal Association of September 2, 1922, The Journal of Nervous and Mental in an editorial captioned "Origin of the Disease for September, 1922, in the re- cerebrospinal fluid" reviews the thories Port of the regular monthly meeting of and the experimental work relating to the Boston Society of Psychiatry and this rather mysterious body fluid. It Neurology for February, 1922, carries has been almost a century since Magen- a rather full review of a paper read at die first described the physical and the that time by Dr. Morton Prince on "An chemical properties of this fluid. With- Experimental Study of the Mechanisms in recent years the importance of the of Hallucinations." "As the result of fluid— from a diagnostic, prognostic, and previous study Prince had come to the therapeutic-reservoir view-point — has conclusion that visual hallucinations enormously increased. It is of the ut- were the emergence into consciousness most importance to know the origin of of normal imagery pertaining to subcon- the fluid, its nature, and likewise its scious processes." The problem for movements and its final destiny. Prince was to find a person exhibiting Strange to say, its course, the course hallucinations who was able to do auto- and the cause of its movements, and its matic writing, without being aware at end are not definitely known. Dandy the time of what she was writing. This produced experimentally unilateral in- writing would constitute in script a por- ternal hydrocephalus by obstructing one trayal of the out-flowing thought from foramen of Monro, but extirpation of the this individual's subconscious. The ex- choroid plexus of a ventricle whose for- periment was performed about as fol- amen of Monro had been so obstructed lows : the subject was seated ; the face was not followed by the development of was covered with an opaque cloth ; a an increased quantity of fluid in the ven- pencil was placed in the writing hand, tricle. But Weed, while looking upon and the hand was placed upon the writ- the above experiment as emphatic evi- ing tablet. The subject was then told to dence of the plexus-origin of the fluid write automatically about some topic within the lateral ventricle, now believes which was suggested in general terms, that these plexuses cannot be the sole If a hallucination developed while the source of the cerebrospinal fluid. It is automatic writing was going on the sub- well known that the centricular fluid ject was instructed to call out at the differs from the subarachnoid fluid beginning of the appearance of the hal- serologically and chemically ; this differ- lucination, "picture," and to indicate the ence Weed believes may be explained in time of the disappearance of the halluci- some degree at least on the assump- nation by saying "gone." In that way tion that out of the perivascular spaces it was easy for an observer to mark on fluid is poured into the subarachnoid the automatically-written script the time fluid, and to the ventricular fluid there of the appearance and the disappearance may be added substances produced by of the hallucinatory image. After the the lining-membrane cells of the ven- automatic writing ceased a written re- tricles. If the spinal fluid do not circu- port was made of the hallucination, and, late there is little use to make of it a according to Prince, "it was easy to September, 1922. EDITORIAL 491 Orthopaedics Alonzo Myers, M. D., Dept. Editor recognize that the images of the halluci- nation corresponded with the ideas re- corded in the script and were such as normally would be the imagery con- tained in those ideas." Prince does not believe that this theory, substantiated . ■■, ^^ , j. ,• ^ here by experimentation, will account A considerable number of splmts ap- for all hallucinations, but he seems in- P^^.^^, to fractures that^are fol owed by clined to think that many visual hallu- I'^'t '^'9}^%'' ^^^^ ^^^^ .P^^ «"^t°° clinations, may be emergences from sub- ^'^^^- ,.^^^8 fault is as serious as hav- conscious states-in much the same ^"^ IP^'",^^ ^°,\l«°^^f. Even splints that manner, for instance, as dreams are are bandaged too tightly may not im- eruptions of sub-consciousness into con- "^f ^l^^^ Continued congestion of the sciousness extremities due to overtightness of a ■ Prince' paper provoked lively discus- ^andage may cause serious stilfnoss in sion and he was subjected to a vigorous ^^e ligaments, faciae, tendons and nius- questionnaire. He stated that the abil- '^^' ^'iJ^out any bony changes what- ity to write automatically-that is ever. Dr. H. Winnett Orr (Am. Jour, of without one's knowing what one is writ- ^^^^-^ ing, is not at all unusual ; that the writer may not even know that she is writing ; Low Back Pain. J. T. O'Ferrall that the writing hand may be indeed an- (Jour, of Bone and Joint Surgery, April, aesthetic; and that normal conscious 1922) summarizes his experience in thought may go on without interrup- these cases, as observed at the Ortho- tion, in association with more or less paedic Clinic of the Touro Infirm.ary, as generalized bodily activity, so long as follows: 1. That the major portion the action is such as not to interfere of the cases of low back paint are believ- with the writing hand. Prince's theory, ed to be sprains of the lumbosacral^ liga- boiled down and made available for the ments, with many superimposed inter- average man, would seem to imply that current infections, including lues. 2. in normal health one crams down into That the location of pain is definitely the mental basement, so to speak, all assigned by the sufferers to the lumbo- thoughts which are useless or disturb- dorsal joint or the lumbosacral angles, ing or distressing or embarrassing in and not in the neighborhood of the sac- the daily life, and that one is generally roiliac joint. 3. That no examiner able to keep these thoughts in sub- does his full duty to his patient nor can mergence by sitting tight and heavy on he arrive at an accurate diagnosis unless the basement lid. Unfortunately, when a careful and complete examination is one becomes mentally disordered or phy- done (possibly excluding the heart and sically toxic and delirious, the thoughts lungs) especially in reference to infec- held in suppression in the basement tious foci; and further, that he insist come tumbling out, and lots of them upon these foci being cleared up. 4. make themselves known as visual and That too much dependence is put upon other kind of hallucinations. It must the x-ray as an aid to diagnosis. It is require a mental and physical Hercu- most useful in determining fractures les to hold the lid down tight all through and real dislocations in and around the one's life. lower spine, but bony anomalies and so- called sacroiliac separation shown should Seventh District Meeting. not be interpreted as the cause for the The annual meeting of the Seventh low back pain, especially in cases of sud- District Medical Society will be • held den onset. 5. That a venereal history October 2-3 at Albemarle, N. C. The and investigation are of great import- secretary reports that already the pro- ance in both sexes. 6. That adhesive gram is well filled with papers discuss- plaster strapping when applied prompt- ing most vitally interesting subjects. ly and firmly to the entire spine gives 4M lOUTHBRN MEDICINE AND SURGERY September, 1922. early relief, but should be supplemented with some form of permanent fixation for a short period after the temporary fixation has been removed. Roentgenology Robt. H. Lafferty, M. D.. Dept. Editor Joint Implants in the Fingers. Oeh- ^^j^^ following article by Moll, K. (Freibourg). lecter reports the present outcome m 8 on Deep Roentgen Therapy in Surgical cases in which an entire joint was trans- Tuberculosis (Bertr. Z. Clin CXIX, P 445) , , , . , ^ . IS synopsized as follows m the July Journa) planted mto a finger over six years ago. ^f Roentgenology.) In 4 cases the joint was taken from the In 1914 Oehler made the first report patient himself; in the others from an- from this (Kraske) Clinic on the deep other person. The results are better in roentgen therapy of this group of affec- the autoplastic cases, and can be regard- tions. During the ensuing four years ed as ideal in one case in which the whole a much larger series of cases has been joint and two half joints were trans- treated. Tuberculosis lymphoma, chief- planted from the second toe into the left ly of the neck has greatly predominated, little finger of a boy of 12. Several In 1918 alone 102 cases have been under enchondromas had been removed from treatment and during the four-term a his fingers, and as he had a talent for total of 263. Deep roentgen therapy is piano playing his parents wanted a by all odds the method of choice for this usable little finger. The joints of the condition. Of the total number under second toe are peculiarly adapted for treatment no less than 219 were practi- transplanting whole joints in this way. cally cured by it alone. Only in a few A partial homoplastic joint transplant instances was it desirable for cosmetic is also liable to prove a success for the reasons to remove the small fibrotic basal joint. The operations on the mid- nodules which could not be further re- dle joint gave only mediocre results. In duced in size. Caseous and fistulous three cases he transplanted the pedun- cases recovered equally with the simple culated big toe in place of the thumb, but hyper-plastic cases, save that scarring the attempt had to be abandoned in one persisted. The response to treatment case as the patient could not stand the was immediate and the improvement discomfort. He used the toe on the very noticeable after two or three ses- same side but Muller advises the op- sions. To complete the cure, time is posite side as more convenient. He required and the author neglects to compares his three cases with nine from state the average duration of treatment, the literature, and illustrates another That 44 cases of lymphoma were not case in which the big toe was grafted cured shows the limitations of the meth- on the stump of the left wrist after the ods ; for while in some of these there hand had been blown off by an explosion, was a greater or less degree of im- To make a clam hand out of the round provement, in others there was no ben- stump, a segment of the radius was re- efit, or the improvement was followed sected, and the toe was sutured to the by recurrence. shortened radius. He also illustrates a The series of cases of bone and joint very successful case of reconstruction tuberculosis numbered 171, and the re- of nearly the entire face after a shell suits were so uniformly good that in wound. The reconstruction was done but 19 of these was a mutilating opera- with pieces from the man's own tibia, tion necessary. The best results were ribe and scapula, besides homoplastic obtained in desease of the hands, wrists material, including a big toe, two fing- and elbows. It is a law that the more er phalanges, and an ear and a lipoma, lender and superficially placed the bone The attempts at free transplantation of the better result ; and for this reason epiphysial cartilage, as done by himself the results were good in the few cases and others, never proved successful. But of tuberculosis of the ribs and the ster- good results have been obtained with num. Of the bulky joints the knees re- pedunculated flaps of the kind. sponded best to the treatment. Of 29 September, 1922. EDITORIAL 4»3 cases in this location 17 were cured This is a great step forward for without a trace of disease remaining. North Carolina womanhood. There is There were relatively few cases of sur- no higher or more noble calling except gical tuberculosis in other locations and true motherhood, results were in general less favorable. In June 1922 Journal of Radiology Geo. E. Phaler M. D. of Philadelphia has a paper on "Cancer of the Lip Treated by Radiation or Combined With Elec- tro - Coagulation and Surgical Pro- cedures." Under Nourishment. He cites many cases and outlines his rpu u i j i.- -n method of treatment in which he uses The worid knows and every nation will Electro-Coagulation. Radiation by eith- concede that its greatest asset is the T, 1- V r» Tj- 14. child. Every mother, who is a real cr Radium or X-Rays. His results are ,, . , '. , , ^ 1, . J , . 4-u i- 11 • mother considers nothing she does for excellent and he-presents the following , , .,, .^ cu j -i. ^ ji conclusions ^ sacrifice. She does it gladly 1 A 'r. , iu 1- and considers it a privilege, even to the 1. Any fissure or crust on the lip . . ^ , ^^.^ ^^ . ,, ,.,,, i.ui 'jij giving of her own life. Every father, which lasts over a month shouid lead . • ^.u i-u 4. A, • 4- , i 1- who is worthy the name puts the inter- one to suspect malignancy. , ^ u *. ^ ^ u- u n o T 114 4- u 1 4. est and best good of his son above all 2. Local destruction by electro-coagu- ,, -j 4.- t 4.u , ,. » „ 1 u 4.U u 1- 4.- other considerations. In the commun- lation, followed b\^ thorough radiation ., ,, -4. • 4. 4. u u , ' \. ,, ,, .f ity no other community interest should should cure practically all cases if ^ , , , u , , j, ,, , , , , ^ ^ take precedence over the matter of the treated early. * ■ • j 4- u- j? ^u o rru u 1- 4.- u 1- training and unfolding of the coming 3. Thorough radiation by radium or ^,,^tion and really, perhaps, no oth- the roentgen rays should be given ^^, .^^^^.^^^ ^^^^ ^J^^^ ^^.^ ^^^_ over the lymphatics draining the dis- ^^^^ ^^^ ^^^ ^^^ ^^^^^^ .^ ^^^^ ^^^ ^^^_ eased area. ^^^^ ^^^ nurses know that from 33 to 4. Recurrent carcinoma gives very ^^ , ^^^^ ^^ ^^^ ^^^.^^^ ^^.^^^^^ ^^^ much less satisfactory results. ^jj^\^,^^ ^^ ^^^^^ ^^^^ ^^^^^, ^^^^.^^_ 5. Metastic lymph nodes should be jnent-underweight-and its various treated by surface radiation and then .^^ u.^tions. It will probably be a sur- by radiation implantation or by excision. ^^.^^ ^^ ^^^^^^^^ ^^^^^^^ p^^^^^^^ ^^^ teachers to know that even in the rural districts where the air is purest and the sunshine brightest the percentage of under nourishment is as high sometimes as 72 per cent — higher than in any of The shortage of student nurses our largest cities, which began with the close of the Because it does not always result in World War has been relieved during direct illness we fail to realize its seri- 1922. All training schools are filling up ousness, and because we have always and the situation arising from .the once seen it we accept the situation as a mat- much talked of pre-training educational ter of course without so much as recog- standards has been relieved by the com- nizing anything wrong. The truth is pulsion of necessity. that under nourishment is the cause of A report from the Nurses' Training lack of appetite, anemia, paleness and School inspector shows in Eastern physical delicacy, abnormal "tiredness," North Carolina 34 training schools in- irritability, tendency to "colds," and is spected with a total enrollment of 425 unquestionably the greatest cause in our and with only 54 vacancies to be filled public schools of unsatisfactory school out of a great number of applicants. All progress. the larger schools are full to capacity, And, don't for one minute get the idea with many young ladies in training who that under nourishment of children ex- are college graduates. ists only where poverty is, for many Hospital and Sanatorium John Q. Myers, 1\I. D., Dept. Editor 494 SOUTHERN MEDICINE AND SURGERY September, 1922. children whose every wish is gratified of the right type were introduced the are starving for real food. Children of results were amazing. Weights ap- frugal families serving plain and often proached normal and in one city after coarse food get more real tissue build- an experiment covering several years, ing elements than some whose natural and taking in 55,000 children, it was appetites are ruined by worthless nick found that youngsters who drank the nacks. right amount of milk at each days Figured in dollars and cents this de- luncheon finished the eight grades of plorable condition is costing the 20un- school work two years younger than try many millions of dollars in the way children who did not have the proper of retarded completion of the public food! school grades, and spent in added teach- If then we leave out of consideration ers salaries, unnecessary school build- the paramount issue of the child's best ings and school equipment, not to men- good and a staunch coming generation tion the much greater loss caused by and think only of our public schools as sub standard or sub developed citizen- a necessary expense which must be en- ship, dured are we going to continue wasting The only remedy for this condition time and money allowing each child to is to teach the motherhood of this land spend two needless years in school? the principles of the balanced ration Are we going to continue to ask for ap- and how to plan and cook meals that propriations to build more school build- will provide adequate nourishment for ings and hire more teachers when the each portion of the body. Obviously this matter of a little wholesome milk and is a physical impossibility for the pres- dietetic instruction will enable the pres- ent generation and the problem must be ent equipment to care for 1-5 to 1-4 approached through the public schools, more children? Is not the matter of The mothers and house keepers of to- having 4 school houses and 4 teachers morrow who are today in school are the accomplish the results of 5 worth think- ones our hope is fixed upon. This meth- ing about? od, too, while building for the future And even though we consider the also gives immediate results today. matter from this sordid and mercinary The matter of the school luncheon and viewpoint the expense of the school proper dietities has proven its worth in luncheon does not need to be born by multitudes of schools and thousands, the tax-payer. If the teacher tells the even millions of children have been child what he needs for his luncheon, helped. those words, "teacher says I must" are The magnitude and tremendous im- magic in most homes, portance of the matter, were first em- The noon meal should be supervised, phasized perhaps almost by accident. Just before luncheon the windows At first, luncheons were introduced only should be thrown wide open and the for the little tots, who were given milk children given 10 minutes of properly and graham crackers at eleven o'clock, directed physical exercise, then let them And perhaps the underlying idea of this file to. the lavoratories, wash their was not so much to supply substantial hands and return with their lunch bas- nourishment for future growth but for kets. If the teaching has been tactful immediate results. "The little tots are these baskets will contain whole wheat hungry, they want (not need) some- bread sandwiches with a filling of egg thing to eat." or cheese, or a little plain or creamed Later the beneficial effects of this be- meat, some fruit and a bit of sweet in ing apparent, older children who re- the form of a simple cup cake, ginger mained over for afternoon sessions, were bread or cookies. One of the children provided with a little something to sup- should then be delegated to give out plement the luncheons they had brought, some clean sheets of paper, which can In some cases small cafeterias were in- be spread upon each desk to serve as stituted and in cases where simple foods tablecloth. Each child should be given September, 1922. EDITORIAL 495 p table napkin and be obliged to sit at The theme of the meeting was "Posi- iiis desk while he eats his luncheon, tive Health" and the program was in- which consists not only of the food he deed a "positive" program. So also was brings from home, but in addition dur- the attendance and general enthusiasm, ing the warmer months, a cup or a Mrs. Dorothy Hayden as presiding offi- bottle of milk, (in which straws have cer, in connection with the program been provided), and in cold months, a committee left absolutely nothing un- cup of cocoa, made entirely of milk, done to make the meeting a positive or a bowl of hot milk soup, such as event in the history of North Carolina cream of corn, cream pea, cream of eel- nursing for the best good of the nursing ery, etc. profession and the people the nurses Will you not agree that this plan serve, would be better in many, many cases Mrs. Hayden was elected president at even for those children who can go the Charlotte meeting in 1920 and was home — or rather run by home and hur- re-elected at Wrightsville in 1921 and riedly snatch up a bite of what may the association will remember with please their fancy and run on to play? much gratitude and pleasure these two To finance such a plan costs very years of efficiency, little. The details for each individual Officers elected were: school can with a little careful consid- President, Miss Pearl Weaver, R. N., eration be worked out in accordance Hendersonv'ille; vice president, Miss with existing conditions. Lois Toomer, R. N. Wilmington ; vice If there is no domestic science or pre-^ident. Miss Rosr Batterham, R. N., cooking class, this furnishes a good ex- Asheville; secretary. Miss Harriett cuse to start one, if any "excuse" is Lesowski, R. N., Raleigh; treasurer, needed. Miss Jessie McLean, R. N., Greensboro. What greater work could any wo- Mrs. Dorothy Hayden, Greensboro, man's club do than to sponsor such a and Miss E. A. Kelly, Fayetteville, were work as this? inexpensive oil or gas elected to serve on the Board of Exam- range, a few utensils, some measuring jners. cups, and a table or two at which yari- ^j^'^ association will hold its 21st ses- ous groups of girls could ake their turn ^.^^ ^^^ ^^i^^ ^^^^ of May, 1923, at at working are practically all that is Roleich needed. But let it cost what it will, results are what count and a better future gen- eration of stronger men and women can- not be valued by dollars and cents. If we will co-operate with nature and ^ ' do more to give nature a chance we will »r. Willis Succeeds Dr. McGuire as do much to cure the need for tonsil Professor of Surgery. clinics or any other of the various school The Medical College of Virginia has clinics of the day. Well nourished, well just made an important change in its developed, healthy childern whose faculty. Dr. Stuart McGuire who has teeth have been well cleaned are not the for a number of years served that insti- ones who make such clinics necessary, tution as professor of surgery has re- Teaching the child teaches the moth- signed and the Board of Visitors at a er today and a properly taugh child to- meeting held September 6 elected Dr. day will be a properly taught mother Murat Willis to fill the vacated chair, tomorrow. Dr, Willis is a young man, 43 years old, but has been closely connected with N. C. Nurses' Meeting. ^.^ig institution as a member of the The North Carolina State Nurses' As- faculty for the past 17 years. He is a sociation held its 20th annual session graduate of the Virginia Medical college September 5, 6, 7 at Greensboro, N. C. in the class of 1904. News Items SOUTHERN MEDICINE A^D SURGERY September, 1922. In 1906 he became associated as a partner with Dr. George Ben Johnson which association continued until Dr. Johnson's death in 1916. In 1910 he was elected Professor of Abdominal Surgery and in 1914 Pro- fessor of Operative Surgery and now he is head of the entire surgical depart- ment of the school. In conjunction with Dr. Johnson he founded the Johnson-Willis Hospital and since the former's death he has continued as head of that institution. He also founded and organized the staff of the Parkview Hospital, Rocky Mount, N. C, but he has now resigned from both of these hospitals. The chair of surgery at the Medical College of Virginia has been held by Dr. Geo. Ben Johnson, Dr. Stuart McGuire and Dr. Murat Willis. will be held on Friday evening in Sym- phony Hall, at which time the fellow- ship degree in the college will be con- ferred upon a group of American and Canadian Surgeons and honorary fellow- ship upon a number of distinguished foreign guests of which there will be almost twenty from South America, Central America and Mexico. In the class receiving the degree this year are a number of men from Virgi- nia and North and South Carolina who have already received notification of their election and there are several others whose applications are still pend- ing. Congress of the American College of Surgeons. The American College of Surgeons will hold its twelfth annual session in Boston October 23rd to 27th, 1922, with headquarters at the Copley Plaza Hotel. Headquarters will be opened for regis- tration Monday, 12 m., October 23rd. The congress formerly opens on Monday evening in the Symphony Hall. On this occasion the distinguished for- eign guests will be presented and the president-elect. Dr. Harvey Gushing of Boston, will deliver his inaugural ad- dress. Professor Raffaele Bastianelli, of Rome, Italy, will present the John B. Murphy Oration in Surgery, taking for his subject, "Surgery of the Joints." As is customary the mornings will be taken up with clinics at the various hos- pitals and in the afternoon and evening scientific programs of unusually high character will be held in the audi- torium. On Wednesday evening the Fellows with the ladies will be guests of the Boston Surgical Society at' a special meeting in Jordan Hall, the occasion be- ing the presenting of the Henry Jacob Biglow Medal to Dr. Wm. Williams Keen, of Philadelphia. The tenth convocation of the College South American Cruise. — Dr. Frank- lin H. Martin with others closely con- nected with the American College of Surgeons have arranged with the Thos. Cook and Son Company for a tour of South America leaving New York Feb- ruary 10th and scheduled to return April 14th. All Fellows of the college and their wives are invited to join this cruise. The itinerary will take in Havana, Panama and down the eastern coast touching at all the important points including Rio de Janeiro to Buenos Ayres. Here, time will be given to make the trans-continental trip by train from Buenos Ayres to Santiago Chile. The expense for this trip depending on accommodation desired will be from $1,100 to $3,000 which will cover all necessary expense. Seaboard Plans Health Program.— Arrangements have been completed with the U. S. public health service, the State Board of Health of South Carolina and the Seaboard Air Line Railway for an extensive survey, by a sanitary engi- neer, of the lands connected with the railroad in South Carolina, with a view to extensive health control along the en- tire line, it was announced by the state board of health in Columbia, July 12. Beginning at Andrews, the malaria sur- vey will be continued to the Savannah River line, and thence to Jacksonville, Fla. September. 1922. EDITORIAL 497 Dr. Micajah Boland, formerly of the Board of Health Organized.— At a Naval Training Station, Hampton meeting called by the mayor, August 1, Roads, has been appointed medical di- the Landrum Board of Health was or- rector of the Gendarmerie d'Haiti, with ganized. Dr. A. R. Walden was elected the rank of colonel, with headquartres president of the board, at Port au Prince, Haiti. Hospital News. — A new $60,000 hos- Nurses Have Police Power.— An pital will be erected at Charleston, S. amendment was recently made to the C, by the Greater Citadel Hospital, city ordinance of Richmond to extend A Tuberculosis clinic has been estab- police powers to certain employes of the lished at the City Hospital, Greenville, health department, so as to include under the auspices of that institution nurses connected with the bureau of and the Greenville County Tuberculosis health. In accordance with this ruling. Association. An appropriation of $6,000 twelve nurses and the chief nurse of additional to the charity fund of the the health bureau were recently sworn hospital was also voted, July 17th. This in with police :)owers. brings the total sum for the charity — • work to $12,000. Physician Escapes Prison.-It is re- The new home for nurses at Colum- ported that Dr. James W. Peacock, bia Hospital to be known as William Thomasville, who has been confined in Weston Hall, was formally opened by the department of the criminal msane the mayor, July 28. The structure is at the state prison, Raleigh, since his named for Dr. William Weston and was acquittal of the killing of Chief of Police erected at a cost of $100,000. Taylor, escaped, August 30, by sliding The contract let for an addition to the down a rope from his cell on the third South Carolina Sanatorium, Columbia, "^*^^- was to be completed September 1. The Julia Irbv Hospital, Laurens, has County Health Lectures.— A health been leased by Drs. Hugh R. Black and campaign has been conducted for sev- Samuel 0. Black, of Spartanburg, and eral weeks in Lenoir County. Physi- ^vill be reopened September 1. cians and dentists have delivered health lectures at various points in the county pr. John Robert Coleman. Shelton, every Thursday night. These lectures s. C. ; Medical College of the State of will be continued through September. South Carolina, Charleston, 1887 ; died July 24, aged 57, at the Pryor Hospital, To Enlarge Barker Memorial.— Con- Chester, from lymphatic Leukemia. struction work is expected to start early this fall on the new home for the Dr. E. M. Yount, Statesville, North Clarence Barker Memorial Hospital and Carolina, is recovering at his home from Dispensary at Biltmore. The orthopae- a serious injurv to one knee sustained die hospital, which was planned for a by slipping while in a fishing boat in separate institute, will be a wing of this ^he Catawba River, hospital, according to a recent decision. The first group of new buildings will be pr. w. R. Whitman, of the staff of erected at a cost of $350,000. the Lewis-Gale Hospital, Roanoke, Va., recently spent a period in post-graduate Dr. John C. Dye, formerly of States- work in the Crile Clinic in Cleveland. ville, has sailed for Honolulu, where he will have charge of the eye department Dr. G. Madison MaxweU, Roanoge, of the Tripler General Hospital. Virginia, was the campaign manager of Judge Clifton Woodrum in his recent Dr. Hunter McGuire Sweaney, Dur- succesful contest for the democratic ham, has been appointed city and coun- nomination for Congress in one of the ty physician. Virginia districts. 498 SOUTHERN MEDICINE AND SURGERY September, 1922. Dr. James W. Vernon and Mrs. Ver- who has been a generous friend to the non, of Morganton, North Carolina, University, have recently spent a two-weeks vaca- i tion period in touring Western North The Medical College of Virginia will Carolina by automobile. begin its fall session on September 13. The dean announces that the first year Dr. W. F. Drewry, Petersburg, and class wil be unusually large. A number Dr. W. M. Smith, Alexandria, have re- of students will be admitted to the Ju~ cently been reappointed by Governor nior class from the Medical Department Trinkle members of the Virginia State of the Univerity of West Virginia and Board of Health. from Wake Forest College. The schools ' of Pharmacy and of Dentistry will also Dr. William H. Parker, of Richmond, be well filled. has returned from a pleasant vacation period spent in Canada. Dr. John Carroll, of Lynchburg, has recently spent a two-months recupera- tive period at Mountain Lake, Virginia. Publications Received THE SURGICAL CLINICS OF NORTH Dr. J. W. Davis, of Statesville, North _ AMERICA Carolina, is completing plans for the (San Francisco Number.) The Surgical Clinics of North America (Is- erection of a private hospital. He has sued serially, one number every other been associated with Dr. F. A. Carpen- month). Volume II, Number 11, (San Fran- ter in the management of the Carpen- "^^^ Number) 259 pages, with 112 illustra- ter-Davis Hnsnital *'""^- ^^"^ ^^^""^ y^^"" (February 1922 to rer uavis nospital. December 1922: Paper $12.00 net Cloth $16.00 net. Philadelphia and London: W. B. Dr. and Mrs. Charles M. Byrnes, of Saunders Company. Baltimore, announce the birth of a daughter— their first born— on August , '^.^'^ """^^"" T^!*"' ! \^^ °^ information on ^ Q , 1 '^ topics of general mterest to any surgeon. The contributors to this volume include a great many of the ablest men from the western Dr. George E. Vincent, president of coast. the Rockefeller Foundation, announces , ^^2 t^'^^t"^^"^ of Fractures of the Mandible J.1 „ , . • -i . .1 TT -i 1 by the use of a Bone-Graft from the clmic the approachmg visit to the United ^f Dr. John Woolsey, the report of a case of States and Canada of a number of dis- Tuberculosis of the Cervix with photomicro- tinguished medical men of Japan. While Ri'aphs from the specimen by Dr. Alferd Baker in this country these eminent scientist S-auIding, the presentation of a series of ,T„-ii xr,-^;4- +u „ • • 1 T 1 J. cases of Spinal Cord Tumors by Dr. Howard will visit the principal medical centers, Naffzi^er. a clinic on chronic arthritis of the and they will be guests of the Rocke- knee joint by Dr. Leonard W. Ely, Tumor of feller Foundation. the Scaprla, Bone Cyst of the Humerus, and a Doubtful Breast Tumor presented and dis- cussed by Dr. E. I. Bartlett, Dr. Harold Brunn The University of Virginia announces on the treatment of Carcinoma of the Recto- completion of the plans for a four-story sigmoid Juncture, Intrathoracic Goitre by Dr. addition on the south side to the Uni- Wallace I. Terry, and several other valuable ,, ;, TT -i 1 T J.1 1 j_ contributions are to be found in this nuni versity Hospital. In the basement pro- |-,gj. vision is made for the care of negro patients — including a maternity and a Volume II, Number ill (Chicago Number nursery department. On the upper '^""^ ^'^^2) 289 pages, with 89 illustrations floors will be quartered the obstetrical „™:' t^t.'iJf-'^onr.u^onf t„fTen and the_ orthopedic departments of the reco-nized authorities of the Middle West. University. The structure will be fire- The well known names of Albert J. Ochsner. proof, and up-to-date in other respects. ^^^^" ^- Kanavel, Arthur Dean Bevan, Carl This much-needed addition to the hos- f^""^' ^^"f^^ ^p^^^' ^"'' *^^^'''^' ^""'^ ^'"^ ^'' • i , . ,1 .-. « ,, ^ , ^ -,, T .. found m the list. pital IS the gift of Mr. Paul C. Mclntire, There is the greatest variety of subjects September, 1922. EDITORIAL dealt with, Stones in the Kidney, Gunshot Wounds of the Kidney, Hyiiertrophy and Car- cinoma of the Prostate Gland, Tumor of the Kidney, Traumatic Kidney, Stone in the Ureter, Mediastinal Abscess, Carcinoma of the Stomach, Tumors of the Spinal Cord, Myxoma of the Jaw, Ec-topic Pregnancy, Carcinoma of the Colon, Sarcoma of the Rib, Common Duct Obstruction and Stricture of the Small In- testine. Volume II, Number 1 (Philadelphia Number) 331 pages, with 145 illustrations. The Philadelphia Number of the Surgical Clinic iiresents a most interesting and val- uable array of surgical facts and principles presented by men who have spent a large part of their time in the teaching of the same things. Dr. John B. Deaver presents a num- ber of diversified cases, and emphasizes im- portant features in hi.s usual forceful manner Dr. J. Chalmers DaCosta discusses an inter- esting case of Tumor of the Pituitary Body accompanied by Abcess of the Brain. Dr. A. P. C. Ashurst presents a series of nine cases almost entirely limited to diseases of the Colon, and the methods of resection of the Colon for malignant disease. The student of Surgical Diseases of the Colon can well profit from this article. Dr. Charles H. Fra- 7ier contributes an article on Brain Tumors in Relation to Cerebrospinal Fluid and Ventri- cles. Dr. Brooke M. Anspach presents a se- ries Gynecological Cases, Warren Davis, on Harelip and Cleft Palate. Muller, Jopson. Speese, Pfeiffer. Rodman, Piper, Jones, Dor- rance. Keene, and Skillern also contribute in- teresting ca.ses. The foregoing statement is recommended to the readers earnest attention. Mitchell and Billings are on the same faculty; so it is not to be doubted that the latter is properly repre- sented when the father of an infant prodigy concludes that it has no special claim to at- tention and "loses his enthusiasm" for it, we can feel assured that its merit has been greatly exaggerated. Great attention is directed to many uncom- mon phases of the subject of syphilis. On the whole it is an excellent synopsis of the past years work in that line. Nervou.s and Mental Diseases. Vo. 8 of the Practical Medicine Series for. 1921. By Peter Bassal, M. D., Associate Professor of Nervous and Mental Diseases. Rush Medi- cal College. This is an eminently practical volume which deals in enough theology to give the reader a sound grasp of the subjects dealt with. Throughout an attempt is made to present the result of work of a high order from various sources, and in the many instances in which different observers have come to opposing conclusions the arrangement is such that the reader can readily get all the evidence on which to ba.se his own opinions. The important subject of tendon and muscle reflexes is clearly and distinctly dealt with. S\in and Venereal Disea.ses. By Ornsby Mitch- ell. M. D., Professor and Head of the De- partment, Skin and Venereal Diseases. Rush Medical College, Being Vol. VII Practical Medicine Series, 1921. A striking footnote is added after an ab- stract of several German articles on focal in- fection as related to certain skin diseases. It's imnortance justifies quotation in full. "Billings and his co-workers who were pio- neers in the eradication of focal infection and subsequent vaccination, have apparently be- come somewhat discouraged and are inclined to lose their enthusiasm in regard to this method of attacking chronic disorders. The epidemic of tonsillectomies and extractions of teeth which followed the work in this country was appalling. In America the epidemic seems to be subsiding, but it appeal's to be breaking out with great violence in England. If dili- gently searched for, focal infection may be found associated with every disease in the index medicus, but this does not prove that the focal infection is the causative factor in all cases." Diseases of the Thyroid Gland ($5.00) by Arthur E. Hertzler, M D. F. A. C. S., pro- fessor of Surgery in the University of Kan- sas School of Medicine; Surgeon to the Hal- stead Hospital, Halstead, Kansas; Surgeon to St. Luke's Hospital and St. Mary's Hos- pital, Kansas City, Mo.; and to the Provi- dent Hospital, Kansas City, Kansas. C. V Mosby Company, St. Louis, Mo. This Monograph represents an excellent portrayal of Thyroid Disease, Its Diagnosis and Treatment, for all practical purposes Complete and still without profuseness, clear concise and beautifully illustrated, this book should always remain invaluable for reference or study. A full chapter on pathology fully illustrated with photomicrographs, and pic- tures of the gross specimen's of thyroid dis- ease is not one of the least attractions of the book. Following this are chapters devoted to the Symptomatology, Diagnosis and Prog- nosis. Hospital Management of Goiter Pa- tients is adequately discussed by Dr. Victor E Chesky. The last chapters concern the treat- ment of Thyroid Disease, and finally there is given "The Technique of Operations on the Thyroid Gland, all well illustrated, and show- ing tie steps in the operations. Other chap- ters in the book include one on The Topo- graphic Anatomy of the Thyroid, and another on Goiters in Unusual Places, intra-thoracic for example. 0 SOUTHERN MEDICINE AND SURGERY September, 1922. Table of Contents for September, 1922 Original Communications. Some Surgical Problems in Reclaiming r. 1 *-• ^ 4.U r^ ^ ivr J- , c ■ . . Cripples, by O. L. Miller, M. D 473 Relation of the County Medical Society to Local Health Work, by J. T. J. Battle, Editorials, M. D 445 The Relation of General Practititioner to ?.u^*^^^V^^'^cVT""r"":^V^ fK" Vr-l Venereal Diseases, by James A. Keiger, J?!,-^°^^t?! S*"^^"* ^"^ Venereal Disease_ 478 ]yi -Q ' 4^g Medical Education 480 T. 1 i.- ' J? T^ 1.T o 1." 1 7 7, ■r-r~~,7r Medical School Committee 482 Relation of Public Schools to the Health Department, by Supt. S. B. Underwood__ 447 Department Editors. Milk Inspection from a Practical View- ^r .• • -.t^ t-> -n x tvt T^ .oo point, bv Mr. J. H. Heald 448 ^^ledicme, Wm. D. Porter, M. D 483 Public Health and Public Welfare Corre- Surgery, A. E. Baker, M. D 485 lated in County Work, by Samuel E. Gynecology and Obsteritrics, Robt. E. Leonard 451 Seibels, M. D 486 Public Health Work in the Schools of Urology, A. J. Crowell, M. D 487 Roberson County, by E. R. Hardin, Mental and Nervous, Jas K. Hall, M. D 488 Health Officer 456 Orthopaedics, Alonzo Myers, M. D 491 Health Work in the Schools, by R. L. Carlton, M. D 459 Roentgeno!o3:y, Robt. H. Laflferty, M. D.__ 492 Progress of Child Hygiene Work in the Hospital and Sanatorium, John Q. Myers, U. S., by Rose Ehrenfeld, R. N 463 M. D 493 An Interesting Case of Aphasia, by A. A. Nursing 493 Barron, M. D 468 News Items. Infectious Diarrhea, by Needham B. Brough- ton, M. D 470 Publications Received 497 Disease of the Stomach and Upper Alimentary sents a complete work in Diseases of the Tract. ($8.00) by Anthony Bassler, M. D. F stomach and upper alimentray tract, service- A. C. P., Professor of Gastro-Eneterology able for reference and study, for students New York Polyclinic Medical School and and practitioners. Anatomy, normal physi- Hospital. and the Late Fordham University ology. Symptoms and Diagnosis and Treat- Medical College, etc. F. A. Davis Company ment are all completely covered. Methods of Publishers, Philadelphia, 1922. ' examination of the stomach contents, the This book of 959 pa-es, and 151 half tone ^^o^ls, etc., are all fully described. There is , ,. ^ ^ ." J r^o J? 11 no little physiological chemistry of the region and line text engravings and 93 full-page .^^^idered. The book seems to really entail plates (with 164 figures) plain and in colors p^ery modern method of diagnosing and treat- from original Photographs and Drawings pre- ing diseases in this area. CLAND-PHOS CO. (TABLETS) GL4NDULAR SUBSTANCE. GLYCERO PHOSPHORUS. VITAMINES. Each Tablet also Contnlns OneTeoih Grain NUX VOMICA INDICATED IN ASTHENIA, NEURESTHENIA AND ANEMIA Take one before each meal and before ret ring SOUTHERN PHARMAGAL GO. GREEiS^SBORO. X. C. 1 ^ 'J Southern Medicine and Surgery Vol. LXXXIV CHARLOTTE, N. C, OCTOBER, 1922 No. 10 IS THE STATE HOSPITAL DOING ITS DUTY? By Albei't Anderson, M. D., Raleigh, N. C, and Victor R. Small, M. D., Raleigh, N. C. Was Nathanael skeptical ? His answer made to Philip: "Can there any good thing come out of Nazareth," would seem to establish the fact of his incred- ulity. Yet, Nathanael was an Israelite in whom there was no guile and it re- quired no miracle to persuade him to cast his doubt aside. However, like Nathanael in skepticism but unlike him in their being unable to see the truth of existing conditions, mar-plots and false prophets, armed with truculent male- volence, have ever been ready to attack institutions of proven worth and cry; "Can there any good thing emanate from such a source?" Criticism, ranging from sly innuendos to open attack, more often destructive than constructive, has from time to time been hurled against institutions that were founded by a spirit of charity. Al- most every institution of merit has at some time been subjected to such an attack, and it would seem, judging from recent articles that have appeared both in medical journals and in editions from the lay press, that state-supported hos- pitals for the care and treatment of the insane have come in to receive their share of this criticism. The State Hospital in Its Incipiency. For three quarters of a century state hospitals for the care and treatment of 502 SOUTHERN MEDICINE AND SURGERY October, 1922. the insane have been functioning insti- tutions in this country. No page of history is more interesting than the story of the founding of these institu- tions by the several states. The treat- ment received by the insane at the time when it was a universal practice to con- fine them in jails and almshouses or to chain them in cellars and garrets, forms one of the darkest tragedies of our social history. However, a pleasing sequel to this story is found in the life of Dorothy Dix, who by her sacrifices and her un- tiring devotion to the cause to which she had dedicated her life, so touched the heartstrings of the people that they responded with a spirit of true benevo- lence and provided asylums for the care of the mentally afflicted. When these institutions were founded they were properly named asylums, and their purpose was to provide custodial care for the insane. At that time an insane person was thought to be poss- essed of evil spirits ; his case was consid- ered hopeless, and any attempt at an effort to improve his mental condition was considered futile. Consequently, little or no treatment was provided. The insane person was simply incarcerated and given food and shelter and whatever care and attention his general condition demanded. If he spontaneously recov- ered, well and good; if he did not re- cover he spent the remainder of his days behind the massive walls and iron bars of the asylum, and society was relieved of his burdensome, annoying presence. This state of affairs was of universal existence until of recent years. Within the past decade the old order has chang- ed. These institutions have elected to be designated as hospitals instead of asylums. This change of name implied a change in methods of administration and treatment, and, in a vast majority of cases, at least in a vast majority of these state institutions in the South, this change has been a reality and not a change in name only. The "drastic reform" in this respect, recently advo- cated by a former president of the American Medical association through the columns of a popular weekly mag- azine, comes as much belated advice. This general revolutionizing of state October, 1922. ORIGINAL COMMUNICATIONS 503 hospital methods, by which it has been made possible to give the patients scien- tific treatment that has in many cases resulted in the patients being mentally restored, received a marked impetus at the close of the recent war. The large number of men rejected for service be- cause of nervous and mental diseases, and the large number of casualties re- sulting from the same cause, brought to the people a realization of the prevalence and the importance of this group of dis- orders. Furthermore, during and fol- lowing the war, great strides were taken by the neuro-psychiatric department of the medical corps of both the army and navy in the diagnosis and treatment of these cases. This additional informa- tion is now available and is being uti- lized. Believing that the methods em- ployed and the work being done at the Dix Hill State Hospital at Raleigh are illustrative of the work that is at pres- ent being carried on at most of the State hospitals of the South, we here- with beg to submit a brief summary of that phase of the work which has a direct bearing on the care and treatment of the patients. A Working Principle for the Hospital. At this institution, through admon- ition and example, there has been in- culcated within the mind of every em- ploye, the idea that every course of ac- tion by the employees, both individually and collectively, must be primarily for the benefit of the patients. Everything must be sub-servient to the patient's interest. This is the spirit of the in- stitution, and the acceptance of this principle enables each and every em- ploye to give his or her very best in service. With this principle of service made effective through work, co-opera- tion, and discipline, there has resulted at this hospital a change from a state of lethargy to one of productive activity. For any person to make of himself or herself a competent employe of an institution of this nature, it is absolute- ly necessary that that person should have the spirit of the true missionary. As pay for a large part of service ren- 504 SOUTHERN MEDICINE AND SURGERY October, 1922. dered he must be content with the feel- ing of peace and satisfaction that comes to him only who knows that his work is being well done, and that he is being instrumental in do'ing something for the unfortunate individuals with whom and for whom he works. No position in the institution, even from the most au- thoritative to the most menial, carries with it a salary or wage sufficient to at- tract or hold for any length of time anyone who works for material remun- eration alone. In an institution of this nature it is essential that each depart- ment be well organized. All depart- ments should be directed from a central head and there must be the proper co- ordination and co-operation of the work of the several departments. Only the work of the medical department will be here considered. The Medical Work. Practically all patients committed to this institution are brought to the hos- pital by one of the two trained social- service workers employed for that pur- pose. These social service workers go to the patient's home and secure by ob- servation of conditions and interviews with the relatives and acquaintances of the patient, valuable information as to the family history, past personal history and home conditions. This information, which could be secured in no other way, forms an important part of the case history. The patients, on their arrival at the hospital, are admitted into one of the specially constructed psychopathic build- ings. These buildings are of very re- cent fire-proof construction, and they are particularly adapted for the treat- ment of acute cases, as they are pro- vided with special equipment for the employment of hydrotherapy, electro- therapy and other methods of treat- ment. The arrangement of the build- ings also permits of classification of pa- tients, a necessary procedure for the most effective medical work. With this in view, each patient after having had a diagnostic survey, is transferred for treatment to the department or ward October, 1922. ORIGINAL COMMUNICATIONS 505 where he or sne is associated with pa- tients of a similar type; thus epileptics are sent to a colony removed some dis- tance from the main hospital buildings ; senile cases are grouped in wards spec- ially provided for them; chronic "low grade" patients are sent to custodial wards ; and the acute cases are held for intensive treatment in the psychopathic buildings. The Diagnostic Survey. Within one week after admission each patient is given the benefit of a diag- nostic survey. This consists of: (1) A complete physical examination, a part of which is a dental examination made by the resident dentist who gives his whole time to the hospital work, (2) A complete neurological exami- nation. (3) An exhaustive mental examina- tion. These, with the exception of the dental examination, are made by physi- cians who have had considerable exper- ience in neuro-psychiartric work. The above examinations are supplemented by: (4) The necessary laboratory work. This is all done in the hospital labora- tory with the exception of the Wasser- mann reactions which tests are made at the State Laboratory of Hygiene, Urine analysis and blood-serum Wasser- manns are made on all patients. Spinal fluid complete analysis are made on all patients who show any one of the fol- lowing clinical findings: (a) Positive or doubtful positive Wassermann reac- tions on the blood serum ; (b) A history or any clinical symptoms of syphillis; (c) Any abnormal neurological symp- toms. Cerebro-spinal fluid for these ex- aminations is withdrawn either by lum- bar puncture or by puncture of the cis- terna magna. Microscopic blood exam- inations, sputum examinations, exami- nations of gastric contents and of feces, are performed in all cases in which there is found any indication for them. The X-ray forms a valuable adjunct in making the diagnostic survey. The dentist utilizes the X-ray in examination i ^ n ' r J i I. ' a. r T T ^ . M. A. '* f™ ^ iPl W '- 1 1 "^'-^ " 1 B^MALE DINING ROOM^^^ i 606 SOUTHERN MEDICINE AND SURGERY October, 1922. of the teeth of more than 90 per cent of the patients. Without its use many infected and impacted teeth would go undetected. After the completion of the above named diagnostic survey, the history and report of the examinations is made a permanent record. The patient is then brought before the medical staff at one of the daily sessions, where the re- port is read, the patient observed, and the case discussed freely. If there is any indication for surgical interference, any indication of special disorders of the eyes, ears, nose, throat or accessory sinuses, or if the case is of unusual in- terest from the standpoint of internal medicine, the case is later brought for consultation to the attenion of some member of the visiting staff. This visiting or consulting staff is composed of eighteen members, six each in the departments of general surgery, internal medicine, and diseases of the eye, ear, nose and throat. This staff of specialists was appointed by the pres- ent governor of the State. This scheme has proven its worth. All members of the consulting staff are eminent physi- cians in their respective fields, and they have given freely of their time and ser- vices. During the past eight months 180 operations have been performed. Methods of Treatment. With the completion of the diagnostic survey actual treatment is instituted. Methods of treatment consist of psycho- therapy, hydrotherapy, electortherapy, occupational therapy, rest, massage, drugs and surgery. We realize that cases must be treated individually and not collectively, and that different lines of treatment are indicated in different individuals. As there is no one etiolo- gical factor responsible for all diseases of the mind, it follows that there is no specific line of treatment applicable to all cases. We recognize a grain of es- tablished truth in the "toxin theory," but we cannot accept it as even a work- ing hypothesis in all cases. This theory, recently advanced, has received wide publicity from both the medical and October, 1922. ORIGINAL COMMUNICATIONS 507 lay press. As any widely heralded "new thing" that promises results bordering on the miraculous is sure to meet with favor, so this theory, unquestioned and uninvestigated, is being accepted by many physicians as well as by the laity. It is but natural that this should be true, for the average physician, more familiar with physical than with mental diseases, has ever been accustomed to think of all the ills to which the human organism is subject as existing on the basis of organic pathology. Further- more, like the proverbial unfortunate man in deep water, we are all more or less prone blindly to grasp at straws. We recognize the fact that bacterial toxins are in a measure responsible for the mental disturbances occurring in a large number of atypical cases which, heretofore, we have been inclined to diagnose as, "Infective and Exhaustive Psychoses." Blindly to accept the the- ory that toxins cause all "functional" mental disorders before the theory has been definitely proven, is a dangerous policy. If, in the minds of the patients or their relatives, it creates hope and trust that cannot be fulfilled, it will be an additional cause for weakening the faith of the public in our profession, for if we make claims that we cannot sub- stantiate, we are in the same class as the common quacks, chiropractors, and other charlatans. Furthermore, this theory, being given publicity and being accepted as a proven fact by the public, is sure to impede the constructive and expansive pohcies of many state hos- pitals. Our axiom in treatment has been to be "conservatively progressive." Any specific line of treatment that has been proven efficacious we have willingly adopted. It is the policy of this hospital to guard against extreme radical ex- perimentation at the risk of the patient, and against the acceptance of unverified conclusions. Such rattle-brain theories as the specificity of the "Bacillus Epil- epticus," the re-section of the colon as a cure of epilepsy, etc., have never found favor at this hospital. Is this method of procedure getting 508 SOUTHERN MEDICINE AND SURGERY October, 1922. October, 1922. ORIGINAL COMMUNICATIONS 509 US anywhere? We believe it is and we base our opinion on the facts that a rel- atively increasing number of patients are being restored to society, a relative- ly decreasing number of these are ever returned to the institution, and a rel- atively shorter period of time is being spent at the hospital by those who re- cover. Medicine is Not an Exact Science. It never will be so long as we are able to make progress, and perfection will not be attained short of the millennium. Let us advance, but let us progress with our eyes open and our wits about us. Let us give due credit to methods which, though not spectacular, are leading us forward. Let us not be so eager in our efforts to advance that we lose sight of sound principles and allow some will- o'-the-wisp to lead us off at a tangent, where we may flounder in conjecture, or where we may travel in a circle of de- struction that leads us back to our start- ing place. Raleigh, N. C. "EMOTIONAL INSTABILITY AS IT RELATES TO DELINQUENCY." William A. Newbold, M. D., Medical Director, Caswell Training School, Kinston, N. C. Social and economic conditions have been undergoing such a radical and rapid chaige that we find ourselves to- day in a world in which it is becoming progressively more and more difficult for the individual to find his place and to maintain it. The present era is one of specialization. We find this exempli- fied in every large industrial center. An employe of a manufacturing establish- ment may work for a life time at some one particular and minute detail with- out ever forming the least concept of the entire process. This specialization of the abilities of the individual begins for the mass of people at an early period of life and results in the inability of that individual to function normally in any 510 SOUTHERN MEDICINE AND SURGERY October, 1922. environment save that for which he swept off his feet and performs some act has been trained. If the individual is which at the time it is being committed then forced to seek employment in some is not under the control of the will. The new field and lacking in experience and following are illustrations: because his initiative has been ground Case One. out of him he fails then goes from one Name-M. F. Male. Age-18 years, job to another never makmg good. p^^^er is living and is forty-nine Havmg failed m all the ligitimate en- y^^^s of age. He is head of a large mer- deavors he then takes the road which ^^^^^-^^ ^^^^^^ ^^^ has always had good appears easiest and becomes a delm- j^ j^^j ^^^^^^^ jje is a graduate of quent. This we believe to be the source ^^^^ ^^^ool and university. History in- of most of our criminals, but there are ^j^^^gg ^^at in early life he was rather many other factors which contribute dissipated and a rather heavy drinker, towards this result. ^^^ ^^^ ^l^^y^ ^^^^ considered a good It takes but a glance at criminal business man, honest, and had the re- records and reports for us to realize that gpect of his acquaintances, a large part of the criminal class is com- Mother is living and is 45 years posed of persons suffering from an ac- of age. Is a graduate of high school tual intellectual deficiency. In fact the and college. Socially prominent. She percentage, although varying slightly has a rather emotional and hysterical with different observers, averages nature. Otherwise the history is nega- around thirty or forty per cent. This, tive. in itself, is a fertile field for observation, ^^^^^^^ j^ ^he onlv child and was con- study, and correction. Physical defects gj^ered as being a very bright and pre- of various kinds, also handicap, some- ^ocious infant. Finished high school times insurmountably the individual ^^^ j^ ^^ present a third year college for maintenance of life. This is too student. The father's statement appears obvious to be dwelt upon. that the child has been petted and We come now to the third factor humored all his life. Earliest criminal which constitutes the subject of this record begins at the age of seven years discussion, namely: "Emotional Insta- at which time, not-with-standing the bility." By this term is meant that ab- fact that he had every luxury which normal psychic condition as a result of wealth could procure, he stole $200.00 which the individual's emotional spheres from his fathers pocket and ran away are so excited that violent and emotional from home, going as far as Albany, reactions are produced by stimulae New York, where he was picked up by which in a normal individual has no a policeman and returned. The mother effect. Ordinarily percepts which considered this action on the part of the reach us from the external world are child as rather humorous and failed to converted into concepts. Before these administer any punishment or discipline, can arise above the threshold of con- The child continued to run away at in- sciousness they receive a certain amount tervals from this time until he was of emotional coloring and are altered fifteen years of age. His history during and controlled by the unconscious com- this period otherwise was negative. plexes. When the level of conscious- When he was about fifteen and one-half ness is reached judgments are formed years of age he was elected treasurer of which acting through the intellect pro- his class and had some few hundred duce some action either mental or phy- dollars intrusted to his care. Nct-with- sical. These acts are always either en- standing the fact that his parents would tirely, or at least to a great extent, un- have gratified any desire, he took the der control of the will. In the emotion- money intrusted to him and went down ally unstable person certain concepts in the lowest parts of the city where he create such a profound emotional dis- remained for several days. When he turbance or a psychic storm, if one may returned home the money was all gone, so speak of it, that the individual is but the parents, of course, made this October, 1922. ORIGINAL COMMUNICATIONS ' 511 good and the fact of his dishonesty was she was fifteen years of age. History i.ever known. The charge for which during this period also negative with he was finally arrested was murder. It the exception that at one time she was appears that^ he fell in love with a girl suspected of taking a few dollars from somewhat older than himself and whose the room of a school mate. This was parents failed to approve of his atten- never proven and the fact did not come tion to her because of his youth and out until later. At the age of sixteen prevented the girl from seeing him. He years she entered one of the large uni- brooded over this for many months and versifies. First and only criminal finally succeeded in communicating with charge was made when the patient was the young woman and met her on a seventeen and one-half years of age at street corner and persuaded her to get which time charge of larceny was en- into an automobile with him. They talk- tered against her. It appears that she e:l the question over. She, having a attempted to steal or pick the pocket little better control over herself and a of a male companion during a dance in better appreciation of the situation, one of the most notorious resorts of failed to agree to elope with him upon New York. which the patient drew a revolver and When the case came to trial the judge killed her. doubting the sanity of the patient or- At the time the boy was examined he dered a mental examination. Evidence stated that if he could not have this girl gathered by the police and social work- no one else should and went to the ers indicated that she had been living meeting with the fullest intention of a dual life for some years. At home killing both the girl and himself. He and in college she held the respect of failed to do the latter, not for coward- the community and school mates, but ness, but when he saw her dead before at certain times she would disappear him the emotional wave was broken and from home, always with plausible ex- he returned to a sane and comprehend- cuse, and indulge in the lowest forms ing knowledge of what he had done, of debauchery. She was alcoholic and When examined the boy was found to a drug addict, yet in the common sense be physically normal, with an intellec- of the word she was sane. She had tual quotient of one hundred and twenty, no hallucinations or delusions. The in- full comprehensive knowledge of the law telligence test indicated that her mental and well defined ethical and moral con- age corresponded with her actual phy- cepts. He was not suffering from any sical age. At the trial the girl was hallucinations, phobias, or any form of acquitted. She subsequently committed psychosis. At present this man is await- suicide. ing trial and will probably be hung or What are we to say of these cases? electrocuted. Neither one is insane and neither one Case Two. is feeble-minded, but both highly emo- Name— A. B. Female. Age 18 years, tionally unstable. Father is living and is fifty years of Nor are these cases exaggerated, they age. Is a college English professor, are taken from actual case histories and Quite unemotional and a brilliant man. are far from being the worst. Mother is living and is forty years of We must now ask ourselves what are age. She received a high school edu- the causes of this emotional instability, cation. She is rather an emotional type how may it be prevented, and how and is rather unsocial. cured ? All of us are acquainted with Patient was born and raised in a many such cases. We see too frequent- small university town. Early history ly young boys and girls belonging to negative. Was considered a normal families of economic and social promi- child somewhat spoiled and humored nence to whom neighbors apply the and was allowed her own way. At the terms wild, head strong, or vicious, age of twelve years she was sent to a Yet how seldom we stop to ask ourselves girl's school where she remained until why this occurs. The causes are many 512 SOUTHERN MEDICINE AND SURGERY October, 1922. and not difficult to find. The present pie. Now, with the oncoming of ma- day parent is so imbued with the idea turity and the tremendous expansion that the one aim to strive for in bring- of ego which' occurs at this time, is it ing up the child is the development of any wonder that parents find themselves individuality, that they forget, if they incapable of coping with the situation? ever knew, the other basic requirements We next come to the public schools. of character, and we find children of In the days of our fathers the first thing but a few years of age, sometimes al- required of the teacher was to maintain most infants, condemned to a life of discipline and order. School attainments uselessness, if not worse, as a sacrifice were secondary. I do not know about to the inordinate, selfish, and criminal North Carolina, but in New York and egotism of the parents. A poor little other northern states discipline has infant who might have otherwise con- passed entirely out of vogue. In talk- tributed his share to the worlds work ing over our subject with a principal is crammed by the loving parent with a of one of the Brooklyn schools she lot of misinformation and taught to re- stated that not only was corporal pun- peat it "parrot fashion" before a room ishment absolutely prohibited, but that full of bored friends who are forced to the teachers were afraid even to speak applaud for politeness sake. The child sharply to the child for fear of inter- thus learns to expect and to strive for vention by "The Society for the Pre- this recognition and the rest of his life vention of Cruelty to Children." There will seek ways and means, no matter is no necessity to dwell on this point how bizarre, to make itself prominent, further as it requires just a little re- The last thing the deluded parent will flection to foretell the results on the think of doing is to throw any obstacle, pupils. as for instance control, in the child's Home and school has been and must way. As a result children are permit- continue to be the institution on which ted to come into adolescence vain, head- we must depend for the moulding of strong, and selfish never having been our future citizens. Just in proportion subjected to any parental discipline, as they function normally so we will They fail to develop any self control and have good or bad citizens, but there are are unstable and emotional, believing other factors which we must consider that the one object of life is the grati- before leaving this phase of the sub- fication of their desires and passions, ject. With the advent of puberty the outlook As has already been pointed out of life is changed. New emotions and we are living in a strenuous age and new desires come to them. Up to this nowhere is this better shown than in time they have been encouraged in the the social lives of our young people. The belief that gratification of desire was simple pleasures and diversions of our permissable. Is it any wonder then fathers have passed away, perhaps for- that they fail at this time to exert that ever, although we hope that this is not self control which is essential for clean true. It v;as once thought that 10:00 manhood and womanhood? The parents or at least 11 :00 o'clock should see every may be aroused now to their predica- boy and girl in bed, but today by that ment and to the knowledge of the essen- time our children are hardly awake from tial necessity of control and guidance the diversions of the night before. What of their children, but too late. Up to have these diversions been? Reckless this time their children have felt the and unchaperoned automobile rides, hand of control, but lightly, have been dancing lasting until the small hours of encouraged in the development of in- the morning, some of which are prop- dividuality, have been allowed to have erly chaperoned, others not, but many their own way, to do the things they permitting licentiousness but thinly desired to do, even when the fulfillment vailed under the cloak of respectability. of these desires meant the sacrifice or The writer does not wish to be under- even the injury of parents or other peo- stood as condemning any of the legit- October, 1922. ORIGINAL COMMUNICATIONS 513 imate pleasures of the young people, ligion has always been and will continue but it requires only a casual observa- to be the idealization of our ethical and tion and a slight knowlege of psychology moral beliefs and without it we are for any one to realize where the present condemned to chaos and deterioration, trends of social intercourse are leading. We must have true fundamental ideals The above picture may not be true in and give them to our children as guides North Carolina, I am not in a position for them throughout life, to say, but I do know that it is true in These then are a few of the factors many places throughout the country, which are the exciting causes of emo- AUow me to repeat the substance of a tional instability. discussion I recently overheard. The It may well be asked how all this may topic being discussed was the lack of be of interest to medical men. When moral standards of the present day. One we come to a study of these cases we young man turning to a friend said, find that many, if not all of them, are "You know that the girls who habit- suffering from disturbances of the en- ually permit the greatest familiarities docrine glands. Many times it can not in public have the strictest moral code." be demonstrated, but often we find When asked for an explanation for this symptoms which indicate, absolutely, apparently ambiguous and contradictory abnormal action of the thyroid, pituitary remark he said that by "moral code" and adrenal glands. According to the he meant actual physical sexual contact. James-Lang theory all emotions are We. as medical men, know the results dependent upon somatic distubances. of any such perverted conceptions of Even though we fail to believe in this sexual life and every one of us have been theory absolutely it is unquestionable called upon to treat psycopathic cases that in a large number of cases of whose mental abnormalities have had as prolonged emotional strain we find mark- their basic these erotic complexes. To ed systemic constitutional change. All the man it makes little difference, but such cases are benefitted by proper rest to the woman it means that she becomes and sedative treatment and by removal accustomed to abnormal ways of sex of the psychic causes. There is another gratifications. This without doubt is way. although less directly, in which we one of the causes for the ever increasing can be of great assistance, especially amount of domestic difficulties and in- the general practitioner who includes compatibilities of married life, conjest- among his duties to act as adviser to ing our divorce courts with ever in- the family. In this way will we be creasing throngs of mal contents. able to exert a vast amount of influence There is one final and most essential upon development of our young people point which must be considered and and the formation of their character, that is the present day trend toward There is no social problem more ^'mpor- agnosticism. It is forever being pointed tant than this one. We must check the out that "Old Fashion Religion" can not appalling increase of the number of withstand the light of our present day those who are socially unadaptable as intellectual advancement. We are told a result of our present day outlook of that the only way for us to maintain our life, the loss of ideals, of standards, of religious views and beliefs is by having morals, and the absence of discipline of supreme faith and by refusing to sub- ourselves, of our home, and of our ject our religious belief to the test of schools. reason. Such views as these but stamped In conclusion permit me to make a the individual holding them as a mon- plea for a return to the saner views of umental egotist. Because we fail in life, to realization that it is not only our finite minds to be able to correlate the duty but the scared privilege of the the few simple physical laws, which we parent to inculcate in the growing child have so far discovered, with the incom- those ethical concepts which are essen- prehensible divine concept but bespeaks tial to its adaptation to society. Let us our inferiority and nothing more. Re- bring up our boys and girls, in such a 514 SOUTHERN MEDICINE AND^ SURGERY 2361 'J3qo:joo way, that they will have the ability To the remainder we must apply the to correctly evaluate themselves and term socially unadaptable. This class will have a correct knowledge of their can only be helped when we come to rea- relation to the environment. This lize the fundamental causes of their must begin in the home and continue criminal actions. We are born with a cer- and finish in the school so that when tain endowment of native or hereditary they reach adult life they will have instincts and emotions. These seek ex- formed a character which will react true pression and fulfillment along inumer- to their environment. Education and able paths. Some of these lead to grati- training will lead to this end. Let us, fication and pleasure and others to pain as medical men, realize that the keynote and non fulfillment. It is by the long of mental functioning is social adap- recognized trial and error method that tability. All this has a medical point of a child learns to take the right path view. Some of these failures, as has and avoid the wrong. In psychological been pointed out, are due to an actual terms the child acquires his learned intellectual deficiency. Let us weed reactions. This begins in infancy and these cases out train them, if training continues through childhood and adol- is possible, place them in such a simple escence. These learned reactions brings environment that they will be able to the individual in contact with his en- maintain themselves or at least be pro- vironment, correct reactions adapt to so- tected and prevented from being a men- ciety and incorrect reactions produce so- ace to themselves and society. The cial outcasts. It is therefore very ap- same must be done for those who are parent that it is absolutely essential to physically handicapped. begin training the child in infancy, lead- The emotionally unstable remain, ing him when we can and driving him The preventive measures for these when we must, but always keeping in cases have already been pointed out. mind that the one object of our training If these fail, as they must even under is to produce an individual who, being the best conditions, we still have a prob- fully equipped, will be able to take his lem on our hands. What are we to do place in the world. It is worse than with these delinquents. Are we to stupid to believe that a child who has condemn them to prison or worse be- been spoiled, humored, and permitted cause, as a result of heredity or environ- to have his own way unchecked and un- mental handicaps, they fail to func- controlled will, when he reaches adult tion normally or are we to consider, as life, leave the shelter of his home and we most certainly should, that they are be able to function normally in his entitled to pity, sympathy, and every changed environment. effort on our part for their betterm.ent and correction? Fortunately our atti- tude in this matter has undergone a HYPER-THYROIDISM AND marked and radical change. Up to with- hvph hvarta ••< in very recent time society took these HYPO-OVAKIA. • social misfits branded them, persecuted them, or even dstroyed them but made ^^^^^«" ^- Bmizer, A. B., M^D., F. A. C. S., no effort to correct the causes underlying ar o e, . . their defects. This change of view point From time immemorial, as pointed has been very gradual. It took many out by Havelock Ellis, it has been the years for us to realize that persons suf- custom in India to measure the necks fering from an actual psychosis or in of brides to determine their defloration legal terms, insanity, should not be and this custom still prevails in certain held responsible for their acts. We next — — — -, , , ,.t ., ^ ^ , o i.u 1 J. ■' J.1 J. ^ SlJlfc . ±^ '. Pathology — The specimen consists of right and lower abdomen, very sugges- the cecum, appendix, 2 1-2 in. of ascend- tive of appendicitis, becoming more fre- ing colon, and 2 1-2 in. of the terminal quent and persistent, the tender mass ileum on either side of the growth in which seemed movable, the rumbling the cecum. There were several enlarged, and gurgling of gas in the intestines very hard glands in the mesentery. The when the pain was severest, the com- growth apparently began in the ileo- plete absence obstructive vomiting, the cecal valve region, and from there it absence of fever and the low leukocyte was spreading through and infiltrating count in a patient of 47 years of age. the wall of the cecum, metastasizing Homans in discussing "The Symptom- into the lymphatic glands, and infiltrat- atology of Carcinoma of the Large Intes- ing through the fatty appendages of the tine" presented by the cases studied and colon. Although there were no obstruc- operated upon in the Brigham Hospital tive symptoms, there was a good deal of Boston calls attention to the fact of stenosis at the ileo-cecal valve caused that in the cecum the feces are liquid, by the contraction of the growth. The and for this reason obstruction is rare, opening was just large enough to admit He states that in general the symptoms the average size lead pencil. Micro- resemble recurring attacks of appendi- scopically, the specimen was adeno-car- citis. In the left haJf of the intestine cinoma, with a very marked and per- where the feces are solid obstruction feet degree of cell differentiation. There and obstructive symptoms are common were metastases to the lymphatic features. Eleven cases of carcinoma of glands which reproduced the exact the cecum are presented from which he glandular structure of the primary tu- draws the following conclusions: "Tu- mor. (Harvey P. Barrett). mors of the cecum cause intermittent Discussion. rather than steadily progressive symp- The diagnostic features of this case toms which may simulate recurrent ap- are the recurring attacks of pain in the pendicitis, or may show themselves as 530 SOUTHERN MEDICINE AND SURGERY October, 1922.' low abdominal colics. The symptoms structures, cannot be considered apart as a whole come late in the develop- from the body as a whole. Assuming ment of the tumor. Patients seek re- that this is not disputed, it may be fur- lief earlier than in cancer of most other ther stated that the dental specialists' parts of the intestine, but the opera- field can no longer be considered limited bility is low. Since appendicitis is imi- by the boundaries of the oral cavity, tated and in some instances initiated by He is engaged in prolonging life and the tumor, much is to be expected by his viewpoint should include the body earlier and more careful operating for as a unit. recurrent or persistent symptoms of Let us see what is demanded of the appendicitis in persons within the can- modern dentist: To solve the problem cer age. Obstruction is not a symptom he daily meets successfully he must be to be looked for." a skilled diagnostician, and as such be The use of the X-ray will frequently familiar on one hand with biology and give invaluable information. There mechanics a.nd on the other with phy- seems to be no choice between the giv- siology and pathology. He must have ing of the bismuth by mouth or by a high degree of technical skill in ad- enema. ' Defects in the cecum may be dition to his general knowledge of med- missed when the enema is given, and icine and surgery. His work carries when given by mouth obstruction in him into the fields of chemistry, bac- the colon may be absent in the X-ray, teriology, metallurgy, physics, electric- but a distended ileum full of gas will ity and art. Without an artistic sense suggest the diagnosis. , In cases of he will fall short of modern standards, doubt both methods should be used. it is true in dentistry, as in general In regard to the treatment, one stage medicine, that each embraces a scope too operations with resection and anasto- wide for an ordinary mind to grasp, and mosis is usually indicated in lesions of of necessity has been divided into spe- the cecum and ascending colon. This cialties, each with its possibilities and of course is so because of the absence its problems. In the past the dentist as a general rule of obstruction in these knew too little general medicine. Those cases. Obstruction anywhere in the in charge of dental education have been gastro-intestinal tract contra-indicates making a sincere effort to correct this. a primary resection and anastomosis- No one will deny that it is desirable ( W. J. Mayo) . The type of the anasto- for the dentist to have a medical de- mosis varies in dilTerent hands. The gree. The dental course now covers lateral side-to-side anastomosis gives four crowded years, and in medicine the good results and is preferred by Moyni- interne year is being rapidly demanded, han. The end-to-end is perhaps the thus it would require a minimum time most difficult, while the end-to-side an- of seven or eight years to obtain both astomosis with the Murphy Button, per- degrees. You will agree that this would fected by C. H. Mayo, is simplest, gives necessitate efforts out of proportion for good results, and seems to us the oper- the end sought. It would be a splendid ation of choice. thing if our medical and dental schools would combine their teachings so as to THE RELATION OF MODERN DEN- grant both degrees within a reasonable TISTRY TO THE PRACTICE limit of time. Aside from the educa- OF MEDICINE. tional problems confronting modern By Guy R. Harrison, D.D.S., Richmond, Va. dentistry let US hope that the modern Associate in Surgery (Oral) and Director of dentist measures up to his responsibili- Dental Department Stuart Circle Hospital; ties. Member Virginia State Board of Health. jn order to place dentistry in its Dentistry is a special field of medi- proper relation to the practice of medi- cine and is related to general medicine cine it is necessary that the medical as any other of the specialties. The practitioner know more of dentistry. I mouth, its contained and adjacent shall speak frankly of this and ask that October, 1922. ORIGINAL COMMUNICATIONS 531 you bear in mind that my statements to the end that our services to our pa- are made with the highest motive of tients be improved. There should be interest to medicine and dentistry, and, dentists on the staffs of hospitals, and above all, for the good of the patient, a part of organized medical groups. The Medical men, as a class, are not inter- selection of the dental member of such ested in dentistry, so do not acquaint staffs should be made only after careful themselves with mouth pathology or investigation as to his ability and stand- the problems the dentist has to face, ing in the dental profession. Unfortu- To the average practitioner of medicine nately, often this is not done. Physi- dentistry consists of filling cavities in cians should be members of dental so- teeth and supplying lost ones. There cieties and dentists of medical societies, is not the spirit of co-operation between Despite the fact that in 1887 the Amer- us that there should be, and the patient ican Medical Association passed a reso- often suffers as a result. Both den- lution declaring dentistry a specialty of tists and practitioners of medicine are medicine and providing for those hold- to be blamed. The correction of this ing the D.D.S. degree to become mem- fault depends upon mutual understand- bers, it is strange that there are very ing and respect. In order for the phy- few medical societies to which dentists sician to understand the problems of are eligible for membership. It may dentistry he should be grounded in the not be amiss to call your attention to fundamentals of dentistry just as the the fact that dentists holding Associate modern dentist is in medicine. No one. Fellowship in the American Medical As- I am sure, would advise teaching the sociation have all the privileges of the under-graduate medical student techni- Fellows. It might be regretted that cal dentistry, but he should be taught comparatively few dentists have availed pathology of the mouth, its clinical rec- themselves of this opportunity. The ognition and treatment to at least equal following editorial appeared in the Med- . the instruction given him in, say: ical Record for March, 1921 : In an ap- Ophthalmology, laryngolory and otol- peal for closer affiliation between the ogy or dermatology; if this were the two professions the editor says: case one would not hear doctors of med- "This mistake of aloofness or assum- icine make a remark like this : "Dr. ed superiority on the part of the medi- So and So must not be a good dentist; cal profession was made when dentis- he filled a tooth for me and the filling try began to acquire a standing as a did not stay in but a short time." branch of therapeusis, with the result Viewed from the biologic standpoint it that the two professions have long ex- is remarkable that foreign, inanimate isted side by side, semi-antagonistic and materials can be used to restore the mutually ignorant of each others' lost part of an organ and the restored teachings. part function, so rather than receive ..j^ jg only recently that the incon- condemnation Dr. So and So should be yenience of this duality in surgical and lauded for his ability to produce dental medical practice has begun to enter the restorations that last and function, in j^j^^jg ^f practitioners of both the pro- some instances, for fifty years or more, fgssions, and in consequence there has Since, as stated in the opening para- been a mutual drawing together of the graph of this paper, dentistry is related leaders in these two branches of the to general medicine as any other of the healing art. The recognition of root specialties, it behooves the members of abscesses and Riggs' Disease as foci of both professions to make every effort infection, bearing upon distant organs to bring about a more cordial relation- and even the brain, has served to show ship. While both professions work to- the mutual dependence of the two pro- gether after a fashion, the rate of im- fessions ; but it was during the late war provement is slow. There should be a that the recognition of dentistry as a common literature and we should meet potential or actual branch of surgery together for discussion of our problems, was effected, this being forced upon the 532 ORIGINAL COMMUNICATIONS October, 1922. Army Medical Department by the bril- riments to an X-ray examination of the liant reconstruction work of the mem- teeth and jaws lies in the prevalence bers of the Dental Reserve Corps, of this examination by those who are There will still be accidents calling for not thoroughly trained in this particu- skilled work of this nature, but it is lar field of work. The mistakes made along the line of preventative medicine are simply appalling and some of the and hygiene that the co-operation of radiodonic interpretations would be a the dentists and physicians will produce joke if it were not so serious." its greatest result. The public will be Roentgen Ray findings should be instructed in mouth hygiene, which is thought of as a symptom; their great- inseparable from general hygiene, and est value lies in their positive findings, for this work reciprocal action of mem- To quote Call : bers of both professions, on the plat- "i doubt if there is any one diagnos- form and in the press, is needed to feed tic procedure from which so much in- the public appetite for knowledge of formation has been expected: if there how to care for the body. is any one method so much relied upon "In many other ways the dentist and to give determining information in such physician could work together to mu- a variety of conditions. The more tual advantage and, as a beginning, an clearly we understand the details of 'exchange of pulpits' would greatly pro- this Roentgen Ray examinations by mote the desired 'rapproachment.' It is watching the procedure, the more seldom that a dentist reads a paper be- clearly we can approximate the value fore a medical society, and a physician of the findings as applied to a partic- speaking before a dental society is a ular case. Like other laboratory pro- still more rare object. This is not as cedures, at times, a sharp cut, unassail- it should be, for practitioners in either able diagnosis can be made without ref- • professions have much to learn from erence to the clinical history of the those in the other, and preventative case and in complete ignorance of all medicine, as well as therapeutics, would facts connected herewith. In majority profit greatly by this mutual instruc- of cases, however, the findings are sug- tion." gestive and explanatory rather than In the study of a case, the physician conclusive." should obtain and act upon the opinion With this I am in entire accord since of a capable mouth specialist, namely : a diagnosis arrived at and treatment of a modern dentist. He should demand mouth pathology based on X-ray exam- from the dentist a real mouth examina- ination alone will often meet with fail- tion arid not an inspection of the teeth ure. for caries only. It is my belief that a when a physician refers a patient to mouth examination should form part of a dentist for an opinion he should sup- an examination of every case studied, piy the dentist with all the information As Vaughan says : "Before one can he has in reference to the case, for we successfully treat any case of illness, it must remember that if the dentist is essential that a correct, as well as a treats the patfent upon the basis of the complete, diagnosis be made." Time mouth being a thing apart from the does not permit me to go into details rest of the body, he is falling far short as to what constitutes a mouth exam- of the measure of his responsibilities, ination, but in my opinion such an ex- j ^.^^jj^^ ^^^^ -^ ^ p^p^^ ^f ^^-^ ^^_ ammation is not complete without a ^ure a discussion of mouth infections Roentgen Ray examination of the teeth, ^^ expected. The time allotted is not jaws and often the maxillary sinuses, sufficient to take up this subject. Per- The X-ray findings should always be m- ^j^ ^^ ^^^^ ^^ incorporate certain con- terpreted by one trained in the clinical elusions I have reached in reference to examination of the mouth. L. R. Main mouth infection: states: 1, There is no such thing as a harm- "To my mind one of the greatest det- less mouth infection. October, 1922. ORIGINAL COMMUNICATIONS 533 2. Mouth infection may be the pri- I have made criticisms of some phy- mary cause of disease elsewhere in the sicians and subscribed to the opinions body ; often it is an influencing factor. of others in the full realization that the 3. Contrary to what is the usual be- sins of commission and omission of lief, in the majority of cases the infec- the dental profession are many. tions about the root ends of the teeth These criticisms have been entirely are of a non-suppurative type and their impersonal and made in an eifort to harm to the body is due to toxins rather provoke progress. than to metastatic invasion by the or- In closing I will quote from a paper ganisms themselves. It is unwise and by Best and Waldron: often dangerous to attempt to eradicate "Between physicians and dentists are by surgical means many chronic oral responsibilities and courtesies which, if foci of infection at one time. The old ignored, are bound to cause trouble- adage "Make haste slowly" should guide whereas, if accepted with full co-oper- us. ation, will mean greater service to the 4. The claim that no pulpless teeth patient. can be safely retained is as absurd as the effort to retain all pulpless teeth, Bibliography. no matter how badly diseased. Physi- 1. Vaughan, Warren T., the Philosophy of cians should not order teeth removed, Medical Diagnosis. Virginia Medical Monthly, nor should dentists carry out such or- May, 1921. ders, unless both are familiar with what 2. Main, L. R. Some Observations of the modern dentistry can accomplish in Radiodonist. The International Journal of eradicating disease about pulpless teeth. Orthodentia and Oral Surgery, February, The same applies to infection of the 1921. investing tissues of teeth. 3. Call, Manfred. Some Points in Diagnos- 5. To attribute nearly every ailment tic Practice, Warwick County (Virginia) Med- to which man is heir to mouth infec- leal Society, 1922. tion is poor logic, but to stop one's ears 4. Best, Elmer S., and Waldron, Carl C. to apparently well-proven facts is equal- Oral Diagnosis and Treatment. The Journal ly illogical. of Dental Research, September, 1921. 6. Whenever the diagnosis of mouth infection is made, we should always re- member that we are dealing with a con- "^""^'^ ^^^"""^ *^^ ^"""^"^^ meeting of the dition that has the potential power of ^'If^^^^ ^^^^''^^ Association, February 22-23, very serious trouble. In many instances there will probably be no ill effects, but the possibilities should always be con- i„ every recent discussion of Malaria siaerecl. ^^^ subject of the relapse phase has become 7. It is not necessary or right to re- of more prominence. move a useful pulpless tooth unless pa- The Rockefellow Foundation report to thologv or bacterial invasion can be ^^^ International Health Board is practi- found. The writer is well aware of the ^^lly devoted to this side of the Malaria fact that the presence of bacteria does Every effort to improve the treatment by not withm Itself constitute disease, but modification of quinine administration has the presence of bacteria withm inter- failed to diminished the importance of stitial tissue; carrying on their life consideration the relapse in Malaria, cycle and the reaction of the tissues to This subject has been ably presented in their presence and function does consti- a Symposium on Malaria including: the tute disease. Rockefeller Foundation report and views Q R^fV, ,^r.A; 1 J J i 1 J? of many authors in a thirty-two page book 8. Both medical and dental profes- Every physician interested should write for sions need more accurate information a copy of the Symposium on Malaria. on this subject, more painstaking, and Distributed free of charge by New York therefore better diagnosis, and a better intravenous Laboratory, 100 West 21st sense of clinical values. Street, New York City. 1922. 534 SOUTHERN MEDICINE AND SURGERY October, 1922. SOUTHERN MEDICINE AND SURGERY J:,^:fZZ^:!Z::^ ZZ Published Monthly by the and sins of omission Were changed to -. , »i ,. ^. , , ,^ sins of commission. Charlotte Medical Journal Company rm. -t. i • tt Then there came an awakenmg. Hon- M. L TOWNSEND, M. D. \ est men set about to protect this credu- J. c. MONTGOMERY, M. D. \ ^*''""'« Jqus public. Pure food laws and drug CHARLOTTE, N. c. Is^^^s, were enacted. Diploma mills were * ' tabooed, and honest men said "It is good." Progress still progressed and "Read not to contradict and confute nor to medical standards were raised. Medical believe and take for granted, nor to find talk .^ . . _^ , , i i- i i ^ and discourse, but to weigh and consider."— Exammmg Boards were established and Francis Bacon. honest men said, "It is good." — Individuals began to amass tremen- dous fortunes and it became a fad, as a A Medical Democracy. propitiation to the Gods to endow, with In continuation of our discussion last these fortunes, educational institutions month of the subiect of Medical Educa- ""^er the guise of making it easier to tion, this journal wishes now to call at- set an education. Again honest men tention to the growing tendency, ^^^^' "^^ ^^ good." throughout the length and breadth of Naturally the faculties of these insti- the land, to restrict educational opportu- tutions took with agility the dictation of nities to young men and women of their benefactors, with the result that means. This tendency is particularly the same tactics used in building up marked in medicine. great fortunes were used to build up a Most assuredly not one of the leaders greater institution. in medical education will admit that this The small, even though worthy, corn- is intentional, and neither do we think petitors were drawing many students it is intended. However, with the rais- and must be crowded out. Taking ad- ing of educational requirements before vantage of the tendency of the times re- beginning the study of medicine, and the quirements, in the way of physical equip- added idea that no one should be per- ment and hospital facilities, were estab- mitted to practice until he has virtually lished so that only the heavily endowed become a specialist, and the greatly in- could meet them. When competition creased expense of going through the was minimized, expenses soared, the curriculum has made it prohibitive for course w^as lengthened, entrance require- thousands of bright young fellows who ments were raised and the poor boy has have the brains and the desire, — young today scarcely a fighting chance to get men who are of the quality of stuff we through. It is absolutely true that the want to see in the profession. poor boy is being driven away from our The poor boy no longer has an equal colleges ; not because he lacks energy, opportunity with the well-to-do in secur- ambition and brains to overcome these ing a permit to practice medicine. barbed wure entanglements, but because There was a time when medical he naturaly turns to other occupations schools sprang u]) most everywhere and where the odds are not so strong against with them came the real menace to soci- him. Opulence does not develop hardi- ety — the dinloma mill. Men, like patent hood and we are getting into our schools medicine, were turned loose on a credu- more and more of the soft by-products bus public who did not give value re- of the comfort of wealth, while the hard- ceived for the money they extracted. In- headed, hard bodied, "poor" boys are ert men like inert patent medicine be- dominating the nation's industries, came a menace by attracting the atten- where men of ability are welcomed, re- t'on, and the substance, of the sick until gardless of their origin or wealth. In disease had destroyed life or at least medicine we are fostering the develop- hope of recovery. ment of an aristocracy and repelling October, 1922. EDITORIAL 535 MEDICINE Wm. B. Porter, M. D., Dept. Editor. men of ability. Eventually the profes- sion and the people must pay the price. We have often said and we again re- peat we want no lowering of medical standards, and we want more efficient _ rather than less efficient doctors, which ~ " ' is just the reason why North Carolina lJ»agnostic Value of Abdominal Pain. should establish a medical school where ^ ^^y (Canadian Practitioner, April men of hardihood, developed by vicissi- 1st 1922), believing that every internal tude, may secure a thorough grounding condition has an external expression, in the funadmentals of medicine. P^^^^^ o^^ the value of pain, tenderness, Such men, if permitted a fighting ^"^ rigidity m the diagnosis of abdom- chance, will develop the qualities within ^"^^ ^^^ Pelvic diseases. Intermittent them and in the process of nature's selec- P^^ i^ indicative of either neuralgia or tion the fit will become more fit ,the me- obstruction, the former being referred diocre will remain mediocre, and the un- to the surface, relieved by pressure. fit will drop out. present along the course of nerves, North Carolina has had medical sharp and darting in character, and in- schools that trained voung men to hon- creased by cold or lower vitality; while estly and cleverlv do for the sick people the latter is intensified by pressure, of the state the things which these sick mainly felt in front, not related to the people wanted and needed done for course of nerves, paroxysmal and wave- ^YiQYYi. ^^^^' gradually reaching intensity and In the state today there are 329 of then subsiding, and increased by stimu- these "Made in Carolinas" doctors who lotion of peristalsis. An intense, sud- are holding up their heads and carrying e'en, tearing pain producing collapse their full share of the burdens. But with vomiting is common in the rup- North Carolina diploma granting med- ture of organs permitting the escape ical schools did not then have the phys- of irritating fluid into a healthy peri- ical equipment to meet the standards toneal cavity, as occurs in rupture of established by the aristocracy and were ectopic gestation, pyosalpinx, appendix crowded out. These self-appointed ^^^^^^^^^ ^^" ^^^^^f' i^'^^^' and duo- . , , J- , J ^- ^u ^ .. (lenal ulcer. In colic the pain is inter- judges of medical education thus drew ^^.^^^^^^^ ^^^ ^^^ abdomen is not rigid unto their own schools those of the ijetween the attacks, while in acute ab- state's young men and women who could dominal conditions the pain is continu- pay the price until their rosters were ous, and accompanied by tenderness and filled and their personal goal reached, rigidity. Rigidity over an inflamed vis- and then the doors were closed, and cus does not occur until its peritoneal ,.^ . ,. ^ ^ , surface becomes inflamed. In mtussus- quahfying applicants turned away. ^^^^.^^ ^^^ p^j^ -^ intermittent, and it North Carolina is proud of her his- -^ ^^ ^^^ height of the paroxysm that tory because she has a history she can -j-j^g intussusception is most palpable, well be proud of. As a pioneer she has because both the pain and the mass are set the pace for the rest of the nation, caused by the increased peristalsis. In She was first to discard an aristocracy palpation the hand should be warm, , , ,. , , , J +•„ gent y applied, and never raised from and establish a wholesome democratic ^^^ J^^^^^n^^ ^^all, but gradually allow- commonwealth as a part of a democratic ^^^ ^^ creep over the surface while the nation. Her courage is not daunted, her patient's attention is distracted by faith is not waning in the principles for questions which require some thought which she has stood. North Carolina to- to answer. The combination of pain and day can do nothing less than stand firmly tenderness is of value in diagnosis, since and squarely for a pure and wholesome in ordinary colic, lead colic, gall stone, Medical Democracy. renal and ureteral colic there is pain, 536 SOUTHERN MEDICINE AND SURGERY October, 1922. but no tenderness ; while both are pres- ent in appendicitis, peritonitis, gall- bladder empyema, or perinephritic ab- scess. The E-Tect of Mercury in Syphilis. Abst. B. M. ., May, 1922, "Heller (Klinische Wochenschrift, March 11th, 1922), brings forward statistical evi- dence against the recent views: (1) that mercury is only a symptomatic remedy and does not influence the course of syphilis and at the best leads to a symptomatic cure, whilst salvarsan alone can produce a true cure; (2) that all cures of syphilis before the salvarsan period are instances of spontaneous re- covery. In countries where anti-syphil- itic treatment is lacking a large pro- portion of tertiary syphilitic cases oc- cur; in no country does spontaneous cure occur, so that tertiary symptoms fail to develop. The statistics of Gluck in Bos- nia show the high percentage of tertiary syphilitic cases in some districts and their great reduction under the influ- ence of mercury given in the early stages of syphilis. Women suffer more frequently than men from severe syphil- itic lesions. In women primary symp- toms are often overlooked and mercu- rial treatment neglected. Syphilis is much more common amongst men. If we allow that the number of syphilitic men is three times as great as the num- ber of syphilitic women, and that wo- men are treated with mercury much less frequently than men, then if mercury has no influence on the course of the disease, especially in preventing severe syphilitic lesions of internal organs, the percentage of syphiliitc lesions found post mortem amongst men should be three times as great as amongst wo- men. But if mercurial treatment in men has an influence, the percentage of severe lesions found amongst men will be less than three times the percentage amongst women. This difference in percentage would be less the more wo- men affected by syphilis, and the more frequently they were treated with mer- cury. Hence the difference would be greater in earlier than in recent time. Heller's collected post mortem statistics show that syphilitic lesions which are influenced by mercury were found much less frequently amongst men than amongst women. In 1881-83 the lesions just named were found amongst women five times as frequently as amongst men (or fifteen times if we allow for the less frequency of syphilis amongst women). In 1911-13 the figures were 2.5 and 7.5 respectively. Heller con- cludes that mercury is not only a symp- tomatic remedy, but that it favorably influence the course of syphilis. So long as it has not yet been proved that salvarsan or other remedies do the same or more (and this can only be proved by pathological anatomy in the next twenty years) the medical man is not justified in discontinuing the use of mercury," The reviewer feels that the facts pre- sented in the above abstract are parti- cularly timely. With the introduction of the simpler arsenical preparations and with the almost universal use of the Wassermann reactions, syphilis is being treated by everyone. It behooves us, therefore, at times to take inventory of our procedures and methods and see just what we are really accomplishing. There is no doubt that syphilis is being treated more universally today than ever before, but is it being treated more efficiently? Are we not becoming too stereotyped in our methods? No one could question the great usefulness of the arsenical preparations in the man- agement of luetic patients, particularly the "primary" and "secondary" stages, yet it is questionable whether we are not doing considerable damage in the employment of more potent arsenical preparations in the treatment of viscer- al forms of this disease. The syphilized liver and heart, in whatever stage of the disease from clinical experience at least, seem to do better when the pro- cess of repair is slow, and when no great strain is placed upon their normal functioning. A "positive" Wassermann is not a complete diagnosis of a luetic subject. A careful study of the patient should precede the beginning of treat- ment, and one's therapy should be re- vised accordingly. A cure of the dis- SURGERY A. E. Baker, M. D., Dept. Editor October, 1922. EDITORIAL 537 eased patient is our real goal not simply opinion as to the nature and cause of the abolition of a "positive Wasser- this complication. This is evident from "^ann." a glance at some of these synonyms, W. B. P. viz: arteriomesenteric obstruction, acute paresis of the stomach, gastro- duodenal dilatation, gastromesenteric ileus, postoperative gastric paralysis, and acute paralytic dilatation of the stomach. ^" ~ ' The clinical picture produced by At the American Medical Association ^cute gastric dilatation is fairly dis- held in Boston, June, 1921, a paper filled tinctive. The most prominent symp- with working knowledge was read by ^o"^ j^"^ vomiting. This, in a large pro- Dr. Emil Novak, on a subject of vital Portion of cases, becomes conspicuous importance to the operator: "Acute ^oon after the operation, so that it is Post-operative Dilatation of the Stom- commonly looked on as merely the usual ach." He emphasized that there are postanaesthetic emesis. In other cases, several reasons why the subject of ^^e onset occurs many days after oper- acute postoperative dilatation of the ^^^o"' Perhaps long after the patient stomach should be of interest to every ^^^ recovered from its immediate ef- surgeon. In the first place, this com- ^^cts. In about one third of Borch- plication is of greater frequency than grevinck's postoperative cases (twenty- has usually been thought. Secondly, it ^^ree of twenty-six) the onset was is very often unrecognized or mistaken ^^ithin the first two days after opera- for some other condition. Finallv, the ^ion. In nineteen cases, vomiting began surgeon's failure to recognize its na- three days after operation ; in five cases, ture is always serious, and not infre- ^^"^ ^^^^ ' ^" ^^"^ ^^^^^' ^^^ ^^y^' ^t^- quently fatal to the patient. There are ^^^ vomiting is characteristically of a few surgical complications in which ^ regurgitant type, the gastric contents early diagnosis is so directly reflected '^^^"^ ^P*^ "P' ^^ ^* ^^^^^' with little in the results to the patient as in the retching or straining. The vomiting one under discussion. As Muller has ^^^^^ ''^^^^ ^^ "o ^^^^^^ ^^ ^^^ patient, put it, "Here the diagnosis is every- appearing to be only an overflow from thing." It is the surgeon who is con- ^^^ stomach, somewhat analogous to the stantly on the lookout for this complica- "binary incontinuence of retention, tion who will recognize it when it pre- '^he amount vomited may be small or sents itself it may be enormously large. In the Although cases of acute gastric dilata- 'f ^ °^^'^^ !} Tf, l'^ vV'f 1', ^^ ^^f tion had undoubtedly been described be- "^ T'^"^^' .M-f ^""'^^^J^^ "^^^^ fore the report of Sir Hilton Fagge in ^" the case of Mi ler and Humby, the l«7q Porfn,-.-.i,r i-uic i-u J stomach after death was found to hold 10 1 6, ceitainly this author deserves <<^ u • i? 1 » T\/r j. .p ^.i ^1, prorijf f^,. +v,« fi». f +1, u '^^^'c^ "Ave basinfuls." Most frequently the credit tor the first thorough presenta- ■. ■, 4. • 1 • • u 1 fi-r.Ti r.f fu^ o.,K- ^ TTi T vomited material is greenish or brown- tion 01 the subject. From a purelv • 1 ^ j. -^ • j-u 1 x 4. pii-niVai ,^..,r,f r.f ; T? T ^, '""y ish, but it may m the later stages Clinical point ot view, Fagge s classic , i i. ui i t u ^ i^a^nr^ir^iLr. ^4? +u ^. ^. 1 ^'**'' .,, become almost black. In a number of description of the symptomatology will _„^„.„^ .„„.. analvses have been made suffice for present day purposes. He ^^Pf^^ted cases analyses have been made Viimcoif co,.o fUof «/i ; .y . " of the vomited stomach contents. Rey- stZf/>. ZL f , / uT ?^ *^! nier found a hyperchlorhydria in sev- fhrnvln,-r ^ ?1 ° obstruction at ^^^ ^f ^is cases, while lactic acid has a cond to. W^^ T^" K^"'^'""' '' been found by iarious observers. In nized " ^"^ '''^^" «"e of "^y '^'^^ the gastric analysis ' showed an absence of free hydrochloric Ihe synonyms of cases of acute post- acid operative dilatation appear in the The large amount of vomitus, far ex- literature under a confusing variety of ceeding the fluid intake, is very char- names, which reflect the difference of acteristic and is to be looked on as evi- 538 SOUTHERN MEDICINE AND SURGERY October, 1922. dence of a marked hypersecretion of the peritonitis, and that it is a more fre- stomach. quent mistake to diagnose acute gastric Pain is almost always a symptom, but dilatation when peritonitis has devel- its severity varies greatly. In some oped than vice versa. On the other cases it has been so excruciating as to hand, it is certain that many patients make the patient scream, while in oth- with acute gastric dilatation have died ers it has amounted to only a feeling of of what has been called peritonitis, or distress in the epigastrium. Collapse postoperative ileus. is noted in practically all severe cases. Pertaining the prognosis — acute oper- the pulse becoming rapid and thready, ative dilatation of the stomach may be the skin cold and moist, the eyes sunken classed as one of the grave surgical and hollow, the respiration rapid and complications. In former years, when shallow. On the other hand, there are it was so commonly unrecognized, the many cases of milder degree in which mortality was very high indeed, but as the general condition of the patient may surgeons are learning to recognize and remain surprisingly good for a consid- treat the complication earlier the mor- erable length of time. Other symptoms tality is showing a gratifying decrease emphasized by almost all authors are from year to year. Neck's figures, in the great thirst and the scantiness of 1906, gave a mortality rate of 73.43 per the urine, both obviously the results of cent ; Laffer, in 1908, gave 63.5 per the great loss of the body by vomiting, cent; Payer, in 1911, gave 53.43 per The two postoperative conditions cent; Borchgrevinck (1913), 54.1 per which are most apt to be mistaken for cent. The latter emphasizes, however, acute gastric dilatation, and vice versa, that of eighty cases in his series re- are peritonitis and postoperative ileus, ported after 1907, the death rate had The differentiation will usually be sug- decreased to 36.2 per cent. No tendency gested by bearing in mind such charac- to spontaneous cure has been noted. Of teristics of gastric dilatation as the ab- thirty-one treated medically or untreat- sence of fever or perhaps the even sub- ed, twenty-nine died, normal temperature, the frequent and As to the etiology and mechanism copious vomiting of regurgitant type, perhaps the most interesting problem the characteristic topography of the in connection with the subject of acute abdominal distention, the absence of gastric dilatation as to the cause and marked leukocytosis, and, most impor- mechanism of the condition. Around tant, the striking if temporary disap- this question there has arisen, as Doolin pearance of the distention after the pas- says, a "riot of theories." Of these sage of the stomach tube. the two which have been most promi- In both peritonitis and obstruction nent are (1) the theory of duodenal the abdominal enlargement is more occlusion by the upper border of the diffuse and rounded, and is not appre- mesentery, with the contained superior ciably relieved by gastric lavage. The mesenteric vessels, and (2) the theory amount of vomitus, and of material re- of paralysis of the muscular wall of the covered by lavage, is also commonly stomach. much smaller. In addition there is usu- Anaesthesia has been much discussed ally more or less fever and leukocytosis as to the part played by the anaesthetic in peritonitis. In postoperative ileus, in the production of acute postoperative again, the onset rarely occurs as early dilatation of the stomach. The fact that as does that of gastric dilatation, pain is many cases are recorded in which dila- more severe, and vomiting is not such tion has occurred in nonsurgical condi- an overshadowing symptom. Further- tions, i. e., when anaesthetic has not more, ileus most frequently involves the an all-important factor in the produc- lower portion of the intestinal canal. tion of the condition. On the other hand, It cannot be too strongly emphasized there is much reason to believe that it that a moderate degree of gastric di- is a predisposing factor of considerable latation is a frequent concomitant of importance. October, 1922. EDITORIAL 539 Treatment of acute postoperative di- probably less infrequent than is gener- latation of the stomach to be succesful, ally believed. must be instituted early. There a few 2. Its early recognition is of vital postoperative complications in which importance to the patient, for on it, to prompt recognition is so important to a lai'ge extent, depends the success of the patient. The diagnostic features of treatment. the condition have already been dis- 3. The use of the stomach tube is cussed. The two principal measures the most important means of diagnosis, for the relief of the gastric dilatation 4. Especially important is the differ- may be discussed briefly as follows : entiation between gastric dilatation, on By gastric lavage the stomach has the one hand, and peritonitis or post- saved the lives of many patients who operative ileus, on the other, have developed postoperative dilatation 5. Dilatation of the stomach is a fre- of the stomach. This fact has not al- quent concomitant of peritoneal infec- ways been appreciated, for, as has al- tion. ready been stated, many a case of gas- 6. The evidence points strongly to trie dilatation has been wrongfully diag- gastric paralysis as the immediate nosed as peritonitis. Fortunately, how- cause of the dilatation, ever, the stomach tube has often been 7. In the primary cases, such as used just the same, to the advantage of those occurring during operation, the these patients. Certainly gastric lavage gastric paresis is explainable as a sim- should be carried out in every case of pie reflex. In the secondary cases, the postoperative dilatation, first for diag- dilatation is the result of septic factors, nostic and later for therapeutic purpo- although it is possible that occlusion ses. In some the distention of the stom- of the upper intestine may in rare cases ach is so great that the tube must be be the primary factor, introduced much farther than usual in 8. The important therapeutic indi- order to evacuate the contents. Prayer cation is gastric lavage instituted early has advised the employment of lavage and given often. in the elevated hip posture, in order 9. There is no place for operative that advantage may be taken of the measures in the treatment of acute post- factor of gravity in facilitating complete operative dilatation of the stomach. evacuation of the stomach. The fre- ^ quency with which the lavage is to be Gynecolog^r and Obstetrics Robert E. Seibels, M. D., Dept. Editor carried out depends on the amount of gas and fluid evacuated. This, as has been seen, is often very great, owing to the extreme degree of hypersecretion Care of the Bladder in Pregnancy, Labor present m many cases. In such cases, ^^^ ^j^^ Puerperium. lavage is often necessary at intervals of every few hours. When the lavage If. as has been stated, pathogenic bac- treatment is instituted early, the results teria are present in the bladders of more are as a rula very gratifying; when be- than 50 per cent of women in labor, the gun late, the treatment may prove of normal changes of pregnancy in the little avail. According to Borch- bladder, plus the injuries of labor, in the grevinck, in forty-eight cases treated opinion of H. W. Shutter, Milwaukee by lavage alone, twenty-four patients (Journal A. M. A., Aug. 5, 1922), pro- got well, and twenty-four died. vide all the factors necessary for the There is no indication for operative production of infection. What, then, is measures in the treatment of acute di- to be the course in preventing and com- latation of the stomach. bating puerperal retention, ischuria and . cystitis. The bladder should be emptied Conclusions. before the woman leaves the delivery ta- 1. Acute postoperative dilatation of ble. As soon after labor as is reason- the stomach is an important and danger- able, she should be urged to void. If nec- ous surgical complication which ia essary, she may be propped up in bed to 540 SOUTHERN MEDICINE AND SURGERY October, 1922. accomplish this. Over distention should find a satisfactory explanation within not be allowed to develop. If the woman the pelvis for backache, rather than ac- cannot be made to void, and in one's cept an uncomplicated retroversion or opinion the bladder is full, she should be retroflexion as the casual factor, Findley catheterized. The care of the bladder has looked to faulty posture, the tilted should not be left to an inexperienced at- pelvis from fatigue attitude, faulty foot tendant. Strychnin, ergot and pituitary mechanisms, sacro-iliac relaxation and extract are sometimes of value in stimu- focal infection. The popular idea that lating the bladder muscles, especially uncomplicated retrodisplacements of the when augmented by the increased intra- uterus results in congestion of the abdominal pressure of the erect posture, uterus, which, in turn, causes such dis- A hot enema, the electric current and turbances as leukorrhea, dysmenorrhea suggestion are often effective. Hexa- and menorrhagia, is not justified in fact, methylenamin, in combination with acid These symptoms are more satisfactorily sodium phosphate, should be given by accounted for by the presence of morbid mouth in most cases in which catheter- changes in the uterus and adnexa. Pres- ization has been necessary. After each sure symptoms referred to the bladder, catheterization, a dram of 20 per cent rectum and pelvic nerves are to be argyrol should be left in the bladder. If ascribed to the presence of gross pelvic pus appears in a urine previously clean, lesions and not to the displaced uterus. daily irrigations of warm sterile boric Prolapsus is the end-stage of retrover- acid solution usually clear the condition sion. Procidentia in nulliparous women rapidly. l is rare and is due to defective innerva- tion coupled with the effects of intra-ab- Frequency and Clinical Significance of dominal pressure. Displacements of the Uterus. An uncomplicated retrodisplacement So-Called Traumatic Displacements of of the uterus in the opinion of Palmer the Uterus. Findley Omaha (Journal A. M. A Sept ^^^^^^^ ^ 2, 1922) IS of no clmical significance ^ ^ ^^ ^^^^^^ ^^^^ ^^^^^ sayethatof aprehmmarystepinthede- ^ displacements of the uterus velopmentof prolapsus. This statement J / symptoms should be qualified m reference to steril- ^J^^ ^^^^^^ ^^^^ ^^j.^^ .^ ^^^^/^^ .^^^_ ity, which for mechanical reasons is m- ,. , , j4.u j- „u-t4- • i ^-p„v,^v.4. r, J . T -4. J J 117-4-1, 4-v,^ diately, and the disability IS only of short fluenced to a limited degree. With the , ,r' ^ + 4. • j- i„„« Dossible exceotion of sterility pelvic duration. Permanent uterine displace- possiDie exception oi sterility, peivic trauma per se. symptoms are chargeable to associated ^ .- ^ 1 • -i-u- 4-1, 1 • J 4- w,^v.^ v,^ Trauma may cause some exaggeration of lesions withm the pelvis and to more re- • j-- • j j- ■, ^v,4- . n , -n 1 • 1 • 4- „,,^ „v, an existing, unrecognized displacement, mote factors. Pelvic complaints are en- , , ^ V , -, -n j j.^ 4. ^.-u I rendered by suggestion, and as a resu. ^^ -f ^^^{„"^tc 7lf:ZfoTe^:' of suggestion the displaced uterus be- ,. ,. ,,,1, •■• j-4--^„ ^^ . 4.1, ^ • • „ bmation of the pre-existing conditions, comes a pam-pathway for neurosis in a ^ ^ woman who has acquired nervous insta- ., ... jr.* -.i- c ^i. bility from overstress. Among 480 re- Anteposition and Retroposition of the troversions and retroflexions, only twen- Uterus: Incidence and Symptoms. ty (4 per cent) were uncomplicated. One thousand consecutive cases of un- The pelvic complications comprised the married women, aged from 15 to 45 whole category of pelvic lesions. The in- years, who had no record of pelvic infec- dications for operative intervention tion, pelvic tumor or pregnancy, were rested in the associated pelvic lesions studied by Leda J. Stacy, Rochester, and not in the displacement of the uterus. Minn. (Journal A. M. A., Sept. 2, 1922) , It was not always possible to account for to determine, if possible, the relative backache, and the correction of the dis- frequency with which the various dis- placement, together with the removal of placements of the uterus and the attend- accompanying pelvic lesions, did not al- ant symptoms occur in cases in which no ways relieve the backache. Failing to pathologic or physiologic factors could October, 1922. EDITORIAL 541 have affected the position of the uterus, competent. To correct these evils, Chal- i.elroposition of the uterus was found in fant suggests a more careful selection of 202 (20.2 per cent). Anteposition, prob- medical students. Students should have ably the normal position in most cases, more systematic instruction in the his- occ'urred in 798 (79.8 per cent) . In view tory of medicine, so that they will have of the fact that the infantile type of the inspiration to be derived from a uterus with which one expects to find de- knowledge of the achievements of the layed menstruation is more often in the past and in that way obtain an inspira- anteposition, it is of interest that in tion for their own work. Sufficient and these cases menstruation was establish- efficient postgraduate schools should be ed at the average age of 13.85 years, and established where the ambitious may be in cases of retroposition, at the average trained. The public should be educated age of 14.18 years. Dysmenorrhea oc- as to the necessity of obtaining compe- curred in 102 (12.8 per cent) of the pa- tent surgical advice. The boards of tients in whom the uterus was in ante- trustees of hospitals should be educated postion, and in thirty -three (16.33 per to a realization of the fact that the care cent) of the patients with retroposition. of the sick is best accomplished in an in- Backache occurred during menstruation stitution in which some research work is in only 7.25 per cent of the 798 patients being carried out. The members of the with anteposition, and in 11.38 per cent staff have a function other than the care of the 202 patients with retroposition. of the sick. They should take sufficient Intermenstrual backache occurred in time to review the work of the depart- 8.39 per cent of all the patients, although ment with the younger men at regular the ratio remained the same in retropo- intervals and to suggest, encourage and sition and in anteposition. None of the supervise some line of investigation. 1,000 patients had marked leukorrheas. Operation for pelvic complaints (practi- The Sheppard -Towner Act in Relation to cally always dysmenorrhea) was ad vis- Public Health. ed for only six (0.75 per cent) of the ^ , , . . . „, ■, . ^ patients with anteposition, and for three 0" ^^%^T\f ^?Z^' ^n 'r rfn,^r (1.48 per cent) of the patients with re- Anna E^^^^^/^Washingt^^^^^^^ C ( Jou - troposition. There seems to be little dif- "^1 A. M. A., Sept. 16 1922) , it is esti ference in the character and incidence "^^^ed that approximately 13.6 per cent of symptoms as a whole in cases of ante- of the total births during the year 1920 position and in cases of retroposition of occurred in hospitals This percentage the uterus Toncrenital retronosition nf varied from 1.7 in Arkansas and Missis- the uteius. Longenital retroposition ot Illinois. Though these the uterus, associated with backache, ^^PP^' lu lu.x m ± - ut „c^ «-p dysmenorrhea and so forth, usually is figures are only approximate because of part of a general picture of deficiency of the admitted limitations of the question- development. Surgical procedure to re- "^^^f "^^thod, they at least Point sign fi- lieve pelvic symptoms in uncomplicated <^^"tly to several phases of thejiospital cases should be advised only after care- Problem in relation to obstetrics. They ful study of the patient from the point «h«^' that there is hospita Provis^^^f^^ of view of the general, as well as the approximately 40 per cent of the births gynecologic, condition. in the United States but that only 14 per cent of the births during 1920 occur- red in hospitals. In this lack of utiliza- Some Gynecologic Misdemeanors. ^-^^^ ^f available hospital facilities for Some of the evils of present-day gyne- confinement care are involved three im- cology and abdominal surgery are con- portant problems: (1) cost of hospital sidered by Sidney A. Chalfant, Pitts- care; (2) inaccessibility of hospitals, burgh (Journal A. M. A., June 3, 1922), and (3) lack of knowledge concerning such as local treatments of the virgin, the advisability of hospital care. Many except for an accidental gonorrheal in- other equally important problems await fection and ill considered and unneces- solution in connection with the hygiene sary operations and surgery by the in- of maternity and infancy. The Shep- 542 SOUTHERN MBDICINB AND SURGERY October, 1922. pard-Towner act is limited to a five-year ishment, the electric chair at work in period. Its fundamental purpose is to its service to society must bring com- enable states to demonstrate for them- fort and satisfaction. Barbaric behav- selves the value of such work in terms ior must be attended to by a public of life saving and improved health, and state barbecue. to stimulate them to develop more com- plete programs for making such work The escape of Dr. J. W. Peacock from effective. The protection of maternity the Department for the Criminal In- and infancy is not the function of one sane — a physical portion of the peni- isolated group, but is dependent on the tentiary — in Raleigh not long ago called obstetrician, the pediatrician, and gen- forth vigorous criticism of the manage- eral practitioner, the public health nurse ment of the institution. The intimation and the social worker in co-operation was that the escape was made as the with the public health authorities. In ad- result of carelessness on the part of dition, it is dependent on the co-oper- the management or by the actual help tion of an enlightened public. of some of those in the employ of the Mental and Nervous James K. Hall, M. D., Dept. Editor State. Dr. Peacock was placed in that particular department of the peniten- tiary soon after he had killed the chief of police in his home town of Thomas- ville. It is not pleasant to contemplate Recently two negroes were electro- the free movement of a man with such cuted in the penitentiary in Raleigh, behavior recently to his credit, but the North Carolina, as the result of con- transfer to an institution of an insane viction of the usual type of assault person does not solve the difficulty, upon a white woman while she was The problem is only transferred. Es- passing through the State as a tourist capes are constantly taking place from with her husband. Press dispatches re- the State Hospitals for the insane wher- ported that the warden of the peniten- ever they may be, and there are po- tiary had requests from more than a tentially dangerous insane persons in thousand persons for permission to see almost every community. There is no the lives of the brutes driven out of solution of the insanity problem. It their bodies by the electric current, can be dealt with satisfactorily only by Because of limited space in the room the aid of characterful, loyal helpers in in which the electrocutions take place the institution that care for the insane, spectators had to be admitted in relays. It would seem that God in His wisdom The newspaper account of the affair creates an insufficient number of peo- tells how the warden of the prison Ple who are fitted for this unrenumera- cracked jokes with a woman spectator tive, thankless, trying, but necessary during the electrocution of one of the service. Securing such service is the negroes, and it would seem that this real problem resting upon the shoulders mightiest manifestation of the state's of every superintendent of every cus- intention and her power to enforce her todial and corrective institution in the laws was attended by little dignity and world. sense of solemnity. Mayhap the thing And now that Dr. Peacock has sue- in all of us is an inheritance from bar- ceeded in making his escape from the barous ancestors who had to live by Department for the Criminal Insane in killing, but the grim feeling of domi- the penitentiary, it might not be amiss nance and joy that comes from wit- for the approaching meeting of the nessing the extinction of an animal's General Assembly to give some thought life is inherent in all of us. In the to the advisability of bringing about sportsman, the desire may find gratifi- improvement in the method of caring cation in the field with dogs and gun; for those unfortunate inmates. The in the warrior, on the field of battle; quarters of the criminal insane are as with those who believe in capital pun- barren as an empty hayloft in March, October, 1922. ' EDITORIAL B4'3 and in the opinion of the Superintend- 7th — In ear conditions, such as ent of the penitentiary that depart- chronic otorrhea, pains referred to the ment of the penitentiary is a disgrace ear, even without any appreciable to the State. And in this opinion the change in the drumhead, are often due Commissioner of Public Welfare con- to Eustachian blockage by the tonsils or curs. The Governor of the State in his adenoids, and their removal should be eulogium of his own administration in seriously considered. Some specialists his recent speech in Charlotte, might advise a tonsilloadenoidectomy if the ear at least have excluded this department discharges longer than three weeks, from the array of State accomplish- (This time limit is questionable.) ments at which he did stretch forth in 8th — Enlarged glands, especially such exultant pride the gubernatorial when tuberculous, should have the most digit. The Superintendent is ashamed probable portal of infection removed; of the department, he said so, and he therefore do a tonsillectomy, ought to know, because he lives most 9th— In some case of keratosis tonsil- of the time in the penitentiary, and laris, when the horny material is limited not in the Governor's mansion. to the tonsils only, their removal is the quickest cure of the condition. Eye, Ear, Nose and Throat J, p. Matheson, M. D., Dept. Editor People are entitled to be freed from this avenue of infection, if it can be done without seriously endangering their There have been a number of articles Ij^es. Therefore, when the tonsils have published lately on the subject of "Ton- been established as the most probable sils." A readable scientific one was pre- source of infections, removal is the log- sented by Dr. Cohen of Philadelphia, '^^^ thing to be done. (New York Medical Journal, May 17, 1922). He emphasized one well-known fact that there are too many tonsillecto- mies being done at the present time. His indications for tonsillectomies are Orthopaedics Alonzo Myers, M. D., Dept. Editor 1st — "The tonsil should be removed Treatment of Congenital Club-Foot: when there is a history of frequent at- John A. Brooke (Hahneman Monthly, tacks of tonsillitis. July) states that braces do not correct 2nd— A history of even one attack of the deformity and should only be used to quinsy requires the removal of the ton- help maintain the correction obtained, sils. Over-correction of the deformity is abso- 3rd— Whenever the tonsils are so lutely necessary if we wish to hold a large as to obstruct breathing, or impair normal position of the foot. Tenotomies voice or speech, the so-called obstructive without full correction and retentive ap- tonsil removal is indicated. paratus are useless. The heel cord should 4th— If one attack of tonsillitis is fol- not be cut until the varus is corrected, lowed by some general disturbance, such When plaster is applied, it should always as rheumatism, cardiac trouble, or ar- come well to the end of the toes. Club- thritis, etc., early removal is advisable, foot properly treated at an early age is a 5th— Embedded tonsils, especially perfectly curable deformity, and in older those pushing the soft palate upward and children and young adults much can be so interfering with Eustachian drain- done to give a useful foot with a mini- age ; the removal of the tonsils should mum deformity, seriously be considered. 6th — In any generalized chronic ail- Subluxation of the Shoulder Down- ment, when the tonsils look suspicious, ward: F. J. Cotton (Boston Med. and with some enlargement of the glands of Surg. Jour.) has found this condition a the neck, and other possible sources of common, though apparently unwritten, infection, such as the teeth and sinuses, complication of shoulder and arm inju- can be ruled out, remove the tonsils. ries. It clears up promptly if treated 544 SOUTHERN MEDICINE ARD SURGERY October, 1922. early, but becomes troublesome if neg- posterior areas and smaller lateral with lected. All the author's nine cases were a target skin distance of 50 cm. and seen in private practice, but many simi- ^ ^^^ ^f Alter. Under the re- lar ones were observed at the hospital; ,, , , , , , , -i • ■,• . eight of the nine were women 40 to 70 '"^^' ^^ '^^^^' ^^^^ ^^^ immediate reac- years old. The author's explanation of ^lon upon the disease is very encourag- the subluxation is as follows : If an in- ing and the improvements generally jured arm is treated with traction by the prompt. The pain is relieved; the dis- weight of the arm, or treated by any charges are lessened or disappear and method that does less than carry the full ^^^ ^^neral condition of the patient is weight of the arm, then, ( ]f the muscles . j * j .. ^i . n • are not strong, and if the arm is a heavy ^"^Proved. And we quote the following one) we may and often do get a stretch- conclusions : ing paralysis of the deltoid and supra- -^e should accept with considerable spinatus muscles that lets the head drop ^^^^^^^ ^^^ ^ ^^ ^^^.^^^ ^^^^l^^ down. This is readily overlooked, but ^ ,, , ^ ^ readily verified by finding a groove below ^^^"^ ^^^ ^^^^ «^ ^"^ European col- the acromion to the outer side, often vis- leagues, but we should welcome grate- ible, always easily felt. If nothing is fully the enormous fund of information done, the condition passes on to one of concerning the physical and biological helplessness and stiffness, at first glance b^gis of deep therapy furnished by them not unlike that of sub-deltoid bursitis, , , . • . . • .^ „,;.;^v, particularly like the form complicated and by our American investigators which with supraspinatus rupture. Treatment, will enable us to make most intelligent after recognition of the fact, consists of use of the shorter wave-length roentgen early massage, and, just as soon as the radiation. A definite advance has been main damage makes it practicable, ex- ^lade in deep radiotherapy. Unprece- change of traction for support, and ef- Rented good results (of at least tempo- fective support, of the whole arm. Un- , . • x v, • j • less too long a time has elapsed, such ^^^^ duration) are being secured in a support with massage gives a prompt re- ^^^^ constant fashion m a larger per- sult — relatively. centage of patients presented for ther- apy. I believe we should discard our old methods just as rapidly as we are equip- ped, not only with apparatus, but espe- cially by a familiarity with the princi- ==^ pies underlying the new method. Ra- in the September, 1922, issue of the dium therapy will be more than ever suc- Journal of Roentgenology Dr. James T. ^^ssful in gynecological malignancies Case has an article on the Technical and , , . ■, .,, ,n • , i,- , Clinical Aspect of the New Deep Roent- ^^^^ combined with the intelligent ap- genotherapy" that is very conservative plication of the new, more penetrating and sane, as is everything that comes X-rays, which by their adaptability to from Dr. Case's pen. In following the conversion into practically homogeneous line of work done in Germany he indi- radiation, will supplement the internal cates that the object of the attack upon use of radium in a manner best calcu- malignancy is to deliver to the area un- lated to reach the lymphatic lines along der treatment one hundred and twenty which extension of the malignant dis- per cent of the skin erythema dose for ease occurs. For benign lesions of the carcinoma and 70% of the skin dose for Pelvis, for which radiation is indicated, sarcoma. This is attained by using areas it cannot be stated that the newer, high from four sides where possible. He uses voltage apparatus is a necessity ; but it in pelvic treatment large anterior and is certainly a great convenience." Roentgenology Robt. H. Lafferty, M. D., Dept. Editor October, 1922. EDITORIAL 545 — N Pediatrics Frank Howard Richardson, M.D., Dept. Ed. ing") are frequently given; not (as any one familiar with the physiology of milk production, human or bovine, might nat- urally suppose) for the purpose of grad- ^ ually drying up the breast and weaning Breast feeding, and universal breast the baby, but because the doctor did not feeding at that, is unquestionably the comprehend that only regular, thorough thing of the hour, in pediatrics. And emptying of the breasts will maintain a writers are just beginning to wake up to milk supply. Dietrich pronounces the the fact that it is not enough for them dictum, "When two or more feedings to urge that babies be kept on the breast are given, weaning is not far off." The (everybody believes this nowadays, in customary silly, inadequate reasons, or theory at least), but that methods of rather excuses, for weaning, commonly maintaining and re-establishing lacta- met with in such cases are tabulated and tion, and the various problems to be met enumerated by Dietrich, simply to show in adjusting the breast to the baby and how utterly many men fail to realize the the baby to the breast, are subjects life and death importance so frequently worthy their very best efforts. Years attaching to the maintenance of this ago, Ross Snyder of Birmingham, one of function, and how cavalierly they treat the most vigorous and convincing speak- a premature weaning. The increasing ers among our Southern pediatrists, and frequency of papers along such lines as this year's section chairman of the this, as well as the remarkably full and Southern Medical, moved that the Sec- illuminating discussion accorded them, tion on Diseases of Children of the A. speaks well for the increasing diffusion M. A. devote as much time to the study of the gospel of simplifying infant feed- of the problems incident upon breast ing by the easiest and most efficient feeding and its conduct, as to artificial method known, — or needed, for that feeding. The discussion accorded the matter. What a commentary upon "su- paper of Dr. Henry Dietrich, of Los An- perscientific" thought, — that we should geles, "Relative to Certain Phases of only now be coming back, as a profes- Breast Feeding (J. A. M. A., July 22, sion, to general acceptation of a truth so 1922, pp. 268 seq.), shows how "live" a obvious that its recognition would seem topic this has become among the best to have been impossible to miss ! children's men. In analyzing 1,000 cases ^ seen in consultation and referred work Clinical and Professional Notes J. Allison Hodges, M. D., Dept. Editor all of whom had previously been seen by other doctors, either obstetricians or general practitioners, Dietrich brings out the startling fact that one-third of these were nursed three months or less ; State Medical Education. and that nearly one-tenth nursed less ^j^g editorial on "Medical Education" than 0726 week. In other words, no seri- j^ ^^e last issue, especially as to the es- ous effort worthy the name was ever tablishment in North Carolina of a full made to keep this one-tenth on the breast four-year Medical College, was as sug- — if the fight were given up as soon as ggstive, as it was sane. It is, also, that. In over nine-tenths of the cases, practical ; for it insists that the State no effort was made to determine the fl^st decide if it needs more doctors, quantity of the milk supply ; so much ^.^^^ whether it can accomplish this simpler, more practical and more valu- better locally, than through outside able a procedure than the so-called milk agencies, and then whether aJl such edu- analysis which one so often hears refer- ^.^^jo^ should be for the purpose of pro- red to as the cause, or rather the excuse Cueing real practitioners of Medicine, for premature weaning. Further fig- qj. for the graduation of specialists and ures prove that two or more bottles research workers, as is the trend of ("substitute" or "supplementary feed- present-day medical education. 546 SOUTHERN MEDICINE AND SURGERY October, 1922. This is a big problem, and one solve it, for her ideals are high, and her fraught with tremendous possibilities, common-sense is pre-eminent! but many preplexing difficulties; it is, Withal, however, the field is inviting also, almost revolutionary in these days to the medical patriot who would strive of advanced standards, for, under the to aid the people at large, who are, at guise and subterfuge of "higher educa- present, the real sufferers because of tion," all sense of proportion, appar- our own drastic and frantic efforts, even ently, is lost sight of, if the "Academic" if partly misdirected, to aid them by standards have been met in a schem- elevating unduly our preparatory stand- atic total of certain "units." ards. Likewise, it must not be forgot- Personally, I would not condemn these ten that schools of medicine primarily methods as wholly reprehensible, for establish contact with the people gen- great good in the general elevation of erally, as no other institutions of high- medical educational standards has been er learning can, or do, for their aim to accomplished, and we need, and must serve the whole people, and at every have specialists, but these changes and angle, they touch every kind of people, advances have in the main been so rad- and every class of disease— to be cos- ical and so swift, that the advancement mopolitan, is their life, technically or, if you please, scientifi- Because of this very fact, and the in- cally, of the student, has been put be- finite variety of cases met in medical tore and above the necessities of the practice, the doctor's professional edu- pubhc; consequently, there are enough cation is concerned chiefly in develop- ot recently graduated "Specialists," jng to the highest degree his ability to but not enough of "Doctors." acquire facts for himself, which shall, ^ In other words, the lure and love of through proper deductions, be made Class A, methods and standards has subservient to the needs of others. This out-weighed the demands and necessi- entails many responsibilities upon a ties ot the people, especially in the rural School of Medicine, none of which can districts. The need, then, is as urgent be ignored without loss to the public, as It IS imperative, that more real doc- and unworthy reductions in the stand- tors be so trained that they shall meet ards and ideals of medical service. It the actual conditions of life, and cer- means practically a laboratory course tainly country-life as it exists today, from start to finish, but this scheme but what can be done, when the pro- with its vast teaching establishments, lessional mind, and even the lay mind, composed of laboratory and clinical has been seduously cultivated for the buildings, administrative halls, libraries last ten years to accept the doctrine that and hospitals, completely equipped and the times require only college training efficiently manned with a well salaried and long years of special preparation faculty, brings one face-to-face with an- tor the prospective doctor, regardless of other responsibility, which is purely his future life work and environments, financial, and yet this is not all, for Can any result other than "Special- while the traditional medical require- ism" harmonize with such teaching, ments of the past might have been sat- and is it unnatural to expect that today isfied with these, the modern methods all graduates should not be "Special- rightly demand, if financially possible ists?" The difficulty, then, is to stem for the student and the college, that the excessive thearetical trend of mod- many correlated branches of medical ern medical thought and teaching, and science also be taught, namely: public still maintain a "Class A" standard, not health work control of disease, the sys- on a thearetical, but a practical basis, tematic education of pupil nurses along which shall select the student, and train sound pedagogical and chnical lines, and the individual in the light of the clin- in many cases, the special teaching of ical necessities of every day profession- Dentistry and Pharmacy, and these in- al life. volve the same conditions and require- I would that North Carolina might ments as were mentioned in connection October, 1922. EDITORIAL 547 with the Medical course, and in turn even by a reputable medical man, and greatly enlarge the financial resqonsibil- much of the so-called treatment is real- ities of any school of Medicine. ly mistreatment. His talk was illus- Practica.lly, then, is it possible to trated by lantern slides, and he gave a teach the fundamentals of medicine and detailed account of his method as a graduate practical clinical doctors, and dentist of treating fractures in various at the same time conform to the stand- portions of the lower jaw. ards of "Class A" methods, and not maintain "an advanced super-scientific "The Clinical Significance of Reduc- institution?" tion in the White Cells of the Human The necessity for a sane and practical Blood" was the title of a rather exhaus- system is evident and imperative; the tive study of leukopema by Dr. Wynd- time is ripe and opportune, but who, ham B. Blanton In this paper Dr. under the taunt of lowering present Blanton discussed the function of the standards, if they should oppose these, leukocyte, its relation to the bone mar- even moderately, will be brave enough row; the mechanism and the classifica- to "buck" the "Standardized" Special- tion of leukopenia; the disease and istic Medical Trust? Shall "academic" the conditions in which the phenome- attainments be the criterion and sole non occurs were enumerated ; and the standard for the future doctor, or shall diagnostic significance of a drop in North Carolina be strong enough, and white cells below the normal was point- wise enough to solve in its own way this ed out. critical problem? Dr. Blanton looks upon the origin of This crisis in medical matters to the white cells as being in the flat bones which we have been brought by these of the body, and in the ends of the precipitate changes in standards, must long bones. The output of these cells be recognized and met, and present and is undoubtedly the result of some kind future requirements must be balanced of stimulus, but the nature of this by necessity and common sense — this stimulus is not known — whether chem- will be "a man's job." ical, nervous, or mechanical— though it . must have a specific quality. The in- fluence which regulates white cell-for- mation must be, he holds, either inhibi- tory or acceleratory. After the cells have been formed and placed in the cir- News Items Richmond Academy of Medicine and '^""'ting blood, they are distributed in Surgery response to chemotactic influence. This T. , ^- o \ ^u^>. 10 ^r.A influence may be either positive or Regular meetings on September 12 and ^^^^^j^^ p^, example, if injected into September 26. ^j^^ peritoneal cavity dead bacilli coli At the first meeting of the Academy ^re immediately ingested by the leuko- after the summer recess on the even- cytes; if the bacilli are alive they are ing of September 12, Dr. Guy R. Har- ^ot ingested. A leukocyte count below rison and Dr. Wyndham B. Blanton pre- 6,000 is looked upon as leukopenia ; a sented papers. count above 10,000 as leukocytosis. A Dr. Harrison discussed the problems considerable reduction in the number of involved in fractures of the lower jaw, white cells may in various ways inter- and he spoke from the viewpoint of his f^re with the normal physiology. The professional training — that of dentis- leukocytes act as defenders against bac- try. His presentation dealt with the terial invaders; they transport certain causes of such fractures, symptoms, food material— as protein substances diagnosis, and treatment. To the sur- glycogen, fat, and proteolytic ferments, prise of many members of the Acad- Influences that reduce materially the emy, he stated that fracture of the lower number of white cells, therefore, will jaw is occasionally not diagnosticated, interfere with these functions. The 548 SOUTHERN MEDICINE AND SURGERY October, 1922. mechanism of leukocyte reduction may able rarity of the condition, the mode be that of white cell destruction ; the re- of transmission, and the method of duction of cells in the peripheral blood making the diagnosis. Although con- may be due to their accumulation else- genital tuberculosis is undoubtedly where; the bone marrow may be pa- rare, Dr. Cook is of the opinion that ralyzed, so to speak, and in consequence it indubitably exists, there is lessened production of the Dr. Cannon spoke on "The New Evi- white cells; the marrow substances dence Regarding the Nature of Wound which give birth to the cells may be Shock." His remarks were based interfered with in its productive activ- wholly on his laboratory experiments ity by the encroachment of malignant and on his own clinical observations and other growths. Leukopenia is a during the world war, and his presen- characteristic of certain diseases— e. g. tation had reference only to that type typhoid fever, influenza, tuberculosis, of shock which he designates as sec- malaria, measles, German measles, KaJa ondary, and as consequent upon physi- Azar, Malta fever, dengue, trypanoso- cal injury. An outstanding feature of miasis, and certain severe types of such shock, easily demonstrated by any pyogenic infections. Reduction in the physician, is fall of blood pressure, both white cells below normal is found also diastolic and systolic. In 75 wounded m pernicious anemia, allied types of soldiers suffering from shock, in whom anemia, chlorosis, hemophilia, and in the normal blood pressure would have simple chronic anemia. Blanton re- been about 120-80, Cannon found an ported m detail 18 cases of an afrebile average systolic pressure of 76, and a type of leukopenia, whose underlying diastolic pressure of 48. Cannon's re- cause was not brought to light. Long- searches have disclosed in addition to a drawn-out use of certain drugs reduces lowered pressure other characteristic the white cell count; amongst these circulatory disturbances. For instance, drugs are mercury, arsenic, quinine, blood volume is enormously decreased, morphia, atropin, alcohol, sulphonal, and the rate of blood flow is brought and lead. Benzol is destructive to leuk- down to about one-seventh of the nor- ocytes. In the presence of a persist- mal rate. The decrease in blood vol- ent leukopenia inquiry should be made ume Cannon attributes to loss of fluid about the use of these drugs, and con- from the circulating blood as it flows sideration must be given to the possi- through the capillary network. This bility of the existence of the diseases liquid constituent of the blood is lost above listed. into the cellular interspaces. The loss Dr. Blanton finally called attention to is brought about by increased capillary the grave prognostic import of leuko- Permeability, and the increased per- penia in a situation characterized nor- meability of the capillary wall is caused mally by leukocvtosis, and to the sud- ^Y the toxic action on the wall of some den transformation of leukocytosis into "^w proteid toxic substance originating leukopenia. Likewise the diagnostic ^^ ^he tissue wound, and absorbed from outlook is made worse as a rule when ^^e wound into the circulating blood, a leukopenia, normal to the condition. Consequent upon the lessened blood- is replaced by leukocytosis. volume, the lowered blood-pressure, the A 4. -4. 1 -• .u decreased rate of blood-flow, are other At its regular meeting on the even- ,, , , a ^.i ing of September 26, the Academy was ^^"-known phenomena. Among these addressed by Dr. Ward H. Cook, Pro- ^'^ P^"°^' P°°^ ^°?^^^ combustion, air- fessor of Pathology in the Medical Col- h""^^^' subnormal temperature, and lege of Virginia, and by Dr. W. B. f^^^T^^^.l Z ' ' • ^1"-,^^'''' ^ 1, • Tu TT- • thinks of the decrease m blood-volume, Cannon, who occupies the Higgmson .-, ■, , j i. i • i j.i • ■D 4? -u- 4? -Du • 1 • TT J the lessened speed at which the remam- Professorship of Physiology in Harvard . „ , 4? ui j • i 4. Ji ,. - - . , mg small volume of blood circulates, University Medical School. and the consequent lowered blood-pres- Dr. Cook's paper dealt with congeni- sure, as central facts in the shock sit- tal tuberculosis. He spoke of the prob- uation. October, 1922. ' EDITORIAL 549 This type of shock, which he desig- The Seventh District Medical Society- nates secondary, he feels certain is not held its annual meeting October 2-3 at due to vasomotor exhaustion. The con- Albemarle, N. C. The attendance was dition is not caused by dilatation of the unusually good and the program was circulatory tubules, as would result, for filled with very high class papers. The instance, from vasomotor exhaustion, opening session was held in Masonic The fundamental change, the causative Hall and was called to order by Dr. Mc- condition, indeed, takes place in the Fayden. This meeting adjourned blood itself, and in the capillary wall, promptly at 10 o'clock and the society Cannon is emphatic in his assertion was taken to the park two miles out that the imperfect oxidation of bodily to a barbecue. tissues resulting principally from Officers for the ensuing year are as slowed blood-flow eventually brings follows : Dr. J. N. Anderson, Albemarle, about the saturation of the blood with N. C, president ; Dr. S. A. Stevens, Mon- noxious poor-combustion products, roe, N. C, vice-president; Dr. Raymond which finally cause irreparable damage Thompson, Charlotte, N. C, re-elected to the central nervous system, thereby secretary. Next meeting will be held in making recovery from this condition Monroe, N. C. impossible. This state he thinks of as a form of acidosis. It has been a long time since the ^^"^ Unit for University Hospital- Academy membership has had a more Plans are nearly completed for a new instructive evening. Dr. Cannon is ac- unit to the University of Virginia Hos- curate in statement, careful, concise, pital. This addition will be located just absolutely lucid and — convincing. His south of the present buildings and will conception of the problem of surgical conform in structure to the north wing shock is new, and if adopted, it will building. It will house the obstetric revolutionize the treatment of the con- and orthopedic departments. This ad- dition, dition was made possible by the $50,000 gift of Paul Mclntire. It is hoped to Raleigh Academy of Medicine Royally complete the building by April, 1923. Entertained. rru T^ i. , T 1 T^- 1 • J TT i. Tuberculosis Conference. The Doctors Lake Fishmg and Hunt- ing Club recently entertained the Ra- The second annual North Carolina leigh Academy of Medicine at their de- Conference on Tuberculosis was held in lightful club grounds, eleven miles out Goldsboro, October 3, at the courthouse, from Raleigh. More than eighty physi- except the morning session of the Med- cians with their wives and friends were ical Section, which was held in the Corn- present, munity House. Dr. C. L. Minor, Ashe- That which was prepared to delight ville, was chairman of the Medical See- the physical man was a sumptuous bar- tion. Dr. J. Howell Way, of Waynesville, becue banquet, after which the academy presided at the afternoon session and formally assembled for its regular Dr. W. S. Rankin, State Health Officer, quarterly session. Dr. Louis N. West presided at the evening session. Mrs. presided and the special feature of in- Gordon Finger was chairman of the terest was a paper bv Dr. J. W. Jervey, Seal Sale Section and Mrs. Charles W. Greenville, S. C, discussing the subject Whitaker, chairman of the Modem of the "Treatment and Diagnosis of Health Crusade. Mastoiditis." Distinguished guests present were The Arion Quartette furnished the Dr. Allen K. Krause, Associate Profes- music for the evening. sor of Medicine, Johns Hopkins, and Among the out-of-town guests were Basil G. Eaves, Campaign Secretary of Dr. and Mrs. J. R. Hester, Dr. Benjamin the National Tuberculosis Association. Hocutt and Dr. G. S. Barbee. % Dr. Krause discussed the subject of 550 SOUTHERN MEDICINE AND SURGERY October, 1922. Nutrition, its Relation to Tuberculosis hygiene and maternity welfare work and other Diseases. Mr. Eaves dis- and to hear reports of what has been cussed the Fundamental Principles of done in the last year toward reducing the Health Crusade. Mr. Wiley H. Swift, the infant mortality rate of the country. National Child Labor Committee, used Herbert Hoover, Secretary of Com- for his subject The Right of the North merce,, is President of the American Carolina Child. Child Hygiene Association and among The entire program was of exception- the prominent men who will address the al quality and this meeting marks a convention are Mr. Hoover, Sir Auck- real event in the State and an epoch in land Geddes, the British Ambassador, the fight against tuberculosis. and Dr. L. Emmett Holt, of New York City. BuIIuck Hospital formally opened its doors Monday, September 4, at Wil- The Medical College of Virginia has mington, N. C. Dr. E. S. Bulluck and incorporated into the curriculum a Dr. R. H. Davis are associated in this course in military tactics and science, new hospital. They have erected a mod- Dr. Charles Wallace Sale, Major, M. C, ern fire-proof and sound-proof structure U. S. Army, will occupy this chair. — three stories and basement — in the heart of the business section of Wil- A Granite Fountain will be erected mington, on North Front Street, near near the Frederick County Courthouse in the Murchison National Bank. The con- Virginia as a memorial to Dr. Godfrey struction is of concrete, brick and steel, L. Miller, who recently died. During and is lined throughout with partition the Civil war Dr. Miller was in charge tile having a sound-deadening space of of all the Confederate hospitals in four inches between all outside walls Winchester. Several thousand dollars and room partitions. have already been raised by public sub- On the main floor there are stores and scription for this worthy cause. business concerns, also the main offices of the doctors, together with general Dr. Hubert A. Royster is convalescing waiting rooms and library, also the X- at his home in Raleigh, North Carolina, ray and chemical laboratories. from a serious illness. On the second floor is located the do- mestic department, including the diet Dr. John A. Williams, of Greensboro, kitchen, main kitchen, dining room and North Carolina, has just returned from laundry, while the remainder of this a tour which included the British Isles floor is devoted to private rooms and and many of the Continental European the patients' parlor. The third floor is countries. devoted exclusively to private rooms. Dr. Royal S. Copeland has recently Dr. K. P. B. Bonner, of Raleigh, Di- been given the nomination for the Unit- rector of the Bureau of Maternity and ed States Senate by the New York State Infancy of the State Board of Health of Democratic Convention. Dr. Copeland North Carolina, attended the thirteenth is a graduate of the University of Mich- annual convention of the American igan Homeopathic Medical School of Child Hygiene Association, at Washing- 1889. ton, D. C, October 12-14. Dr. Bonner . will serve as a delegate from Raleigh Dr. John A. Owen, of Turbeyville, and take part in a special session of Virginia, was a delegate to the Presby- Directors of State and City Board of , . „ j i. -4. j. 4.- • r^^,■^J TT • terian Synod at its recent meeting m Child Hygiene. ^. ^ ^, tt • u ^ ^v, T> , . u, J , , . .1 ,^v,4-;^v, Richmond. He is a member of the com- Raleigh s delegate to the convention will be one of several hundred from all "^^ttee of that body authorized to estab- parts of the United States who will meet lish a Presbyterian college for women to discuss the various phases of child in the State of Virginia. October, 1922. EDITORIAL 551 Dr. Frank S. Johns, of the surgical ognition to the ministry of healing. In rtaff of the Johnston-Willis Hospital in consequence of this official action, cler- Richmond, has recently spent a consid- gy and lay members who believe they erable study-period in the Mayo Clinic, possess the power of healing are au- thorized to prepare themselves "by care Dr. George A. Stover, of South Bos- and prayer and theological and medical ton, Virginia, is rapidly recuperating at study for their proper and safe exer- his home after a serious operation per- cise." formed in St. Elizabeth's Hospital in Richmond. Dr. R. H. DuBose, of Roanoke, Vir- ginia, was married in East Orange, New The Johnston-Willis Hospital in Jersey, on October 4th to Miss Lucy Richmond has just secured a building Ross. permit for the erection of a hospital building. The new institution will cost Dr. Edward C. Smith, born in 1864, two hundred thousand dollars, and will and a graduate in medicine of the be located just off the Boulevard, near University of Virginia in the class of the Battle Abbey. 1881, died on September 15 at his home in Richmond, Va. Dr. Albert Anderson, Superintendent of the State Hospital, Raleigh, North Dr. George Victor Litchfield, Jr., Ab- Carolina, has just returned home from ingdon, Va. ; Johns Hopkins University, a meeting of the American Hospital As- Medical Department, Baltimore, 1902 ; sociation in Atlantic City. served in the M. C, U. S. Army, with the rank of captain, during the world Dr. Barksdale Hales died recently at war ; died suddenly, August 29, aged 45, his home at Pounding Mill, Pulaski from heart disease. County, Virginia. He was born in 1858, was graduated in 1880 from the Medi- Dr. McDugald Keener McLean, Ashe- cal College of Virginia, and in 1882 ville, N. C; Johns Hopkins University, from the College of Physicians and Sur- Medical Department, Baltimore, 1915 ; geons in New York. For many years author of "Tuberculosis — A Primer and he practiced at Fredericksburg, Vir- Philosophy for Patient Public;" died ginia. September 8, aged 36. Dr. W. S. Halstead, Professor of Dr. Jesse Romulus Ballance, Bolivia, Surgery in Johns Hopkins Hospital, N. C. ; North Carolina Medical College, died in Baltimore on September 7. He Charlotte, 1912; aged 45; was found was born in 1852, and was a graduate dead on the street in Kenansville re- of the College of Physicians and Sur- cently, from acute indigestion. geons of New York in the class of 1877. New Chair at Medical College— The board of visitors of the Medical College Dr. Gavin Rawls died at his home at of Virginia, by unanimous vote, have Carrsville, Virginia, on September 28. added a course in military tactics and He was born in 1856, was graduated science. Dr. Charles Wallace Sale, Ma- from the Medical College of Virginia in jor, M. C, U. S. Army, has been ap- 1876, and for several years he had been pointed to the professorship of this superintendent of schools in Isle of chair. Wight County. „ ~~~ . . ^. Honor Memory of Physician — More Press dispatches reported that the than $2,000 has been raised by friends Protestant Episcopal Church of the of the late Dr. Godfrey L. Miller, Win- United States, at its recent general con- Chester, Va., for the purpose of erect- vention in Portland, Oregon, gave rec- ing a memorial. This will take the form ssz SOUTHERN MEDICINE AND SURGERY October, 1922. of a granite foundation to be erected near the Frederick County court house. Dr. Miller was in charge of all the Con- federate hospitals in Winchester dur- ing the Civil War. sive additions. He was a member of the State and American Medical Associa- tions and a Fellow of the American Col- lege of Surgeons. It is reported that the British Gov- ernment has decided to drop from all official literature the term, "Shell Shock." Dr. W. S. Rankin, North Carolina State Health Officer, is making active preparations for beginning a campaign on malarial control in the eastern part of the state, early next year. Dr. Charles H. Frazier has succeeded Dr. John B. Deaver, resigned, as John Rhea Professor of Surgery, in the Uni- versity of Pennsylvania. Dr. N. A. Thompson, Lumberton, N. C, died September 28 as the result of in- juries received, when run down by an automobile at Fayetteville. He with a party of friends had gone to Fayetteville for the evening and when crossing the public square was struck by the car and killed almost instantly. Dr. Thompson was 52 years old and since 1906 has owned and operated the Thompson Hospital at Lumberton to which he had just recently made exten- Dr. H. W. McCain, High Point, N. C, died October 3 as a result of infection from a carbuncle on his neck. He had been in critical condition for some days, so that death was not unexpected. Dr. McCain was born in Union Coun- ty, N. C, February 27, 1882. He re- ceived his A.B, degree from the Univer- sity of North Carolina, and his M.D. de- gree from Jefferson Medical College. He located in High Point in 1911, first being associated with Dr. Reitzel, but after his death he became associated with Dr. J. T. Burrus in the High Point Hospital. He was a member of the County, State, Tri-State, Southern and American Med- ical Societies, also of the Masonic Lodge, the Elks and Kiwanians. His widow and one daughter survive him. Dr. George M. Gould recently died at his home in Atlantic City. Dr. Gould's name, as well as his personality, was known throughout the world, — and cer- tainly no medical student of recent years has not often felt eternally grateful to Dr. Gould for compiling his dictionary and encyclopedia in pocket size edition, thus enabling them to answer the un- answerable questions when the proper answer was sorely needed. Dr. Gould's researches in the field of optical disorders, however, were his greatest monuments, and entitle him to eternal fame. His "Biographical Clin- ics" are specimens of his thorough scholarship. For a long time he con- ducted that splendid medical journal, "American Medicine." Dr. Gould's death leaves a vacancy in the ranks of the medical profession which will be deeply felt. Dr. Alexander R. Craig, Secretary of the American Medical Association con- tinuously since 1911, died suddenly of uraemia, at the age of 54, on Septem- ber 2, while on a vacation at Fort De- posit, Maryland. He was a native of Columbia, Pennsylvania; a graduate in October, 1922. EDITORIAL 85* medicine from the Medical Department 3,328,000 doses. Caster oil is another big of the University of Pennsylvania in item on the laxative list, and there are the class of 1893 ; and he had served as others. chief resident physician at the Philadel- The quantities are stupendous, but so phia Polyclinic Hospital. He had prac- is the need. Hospital after hospital, ticed medicine in Columbia, Penn., and dispensary after dispensary has found in Philadelphia. His genial personality itself unable to compound the simplest endeared him to his acquaintances and prescriptions because of the lack of to his business associates, and he made many common and generally used phar- an ideal Secretary of the Association, maceutical preparations. Malaria which is becoming increasing- Questionable Certificates. ly prevalent in Russia has raged practi- "Because of the many cases dismissed cally unchecked because quinine was because of illness of the defendant who almost unobtamable. America's contri- f urnished a physician's certificate, Judge *^"tion of qumme is 20,000 pounds. Any- Ervin addressed a letter to the Mobile one who has inadvertently bitten into Medical Society calling attention to the ^ ^^'^ grain quinine tablet can realize apparent promiscuous issuing of these what a bitter pill Russia has to swallow, certificates and stating his desire that ^ ^^n ton pill of quinine not counting the relations which have always existed the weight of the sugar coating, between the bench and the medical soci- ^^ ^^s^ia should cut its finger there ety remain cordial, based upon mutual would be no immediate lack of dress- confidence and trust. He further asked '"^s- I" the first place if the cut is not that members of the society be informed ^ serious one there are 80,000 bottles of of his desire that certificates state the collodion, to be applied after half a mil- disease from which the patient is suffer- 'ion tubes of lodme had been used to ing and the physician's opinion as to his cleanse the wound and 1,200,000 iodine ability to attend court." swabs had been used to wipe it out. If it were more serious, even if it were Purging Russia. ^^ Mercultio's was not, "so wide as a church door nor deep as a well," there Moscow, July 13. — If medicine could would be bandages enough and to spare. cure the body politic, Russia by now The A. R. A. has received for distribu- ought to be on a fair way to recovery, tion 21,600,000 plain gauze bandages The American Relief Administration is and more than 6,000,000 yards of com- pouring medicine into the Soviet Repub- pressed gauze bandages and over half lie not by teaspoonful but by the ton. a million pounds of cotton. The Psalmist of old sang, "Purge me ^he A. R. A. order for neo-salvarsan, with hyssop and I shall be clean, wash .^hich is regarded as a perfect specific me and I shall be whiter than snow." f^^. tvphus recurrens as well as for If purgation has a corresponding ef- syphilis, to date totals nearly half a feet upon Russian red that fiery hue j^f^iuion tubes ought soon to be reduced to at least a ^^^^.^^ ^^ ^^^ distribution pa e pink, for one of the items on the ^^^ ^ ^^1^^ ^^^^^^1^ -^ ^^^^^^_ list of surplus army medical supphes ^ ^^^^. ^^^ ^^^^1 ^^ sent to Russia is 52,000 pounds oi Ep- ^^^ ^^^.^^^ department of the A. som salts. No one who served with the ' ^^^ ^^^^^ ^^ 1,000,000 pounds A, E, F in France would quite beheve ^^ hospitals, homes and in- it possible considering the number of ,., ,• "C.C." pills consumed by the American stitutions. Army, but it is a fact that the surplus The 400,000 pounds of sulplur wh.ch sent to Russia is 50,000,000. Epsom it has received and is distributing, if salts used with discretion yield some 64 delivered to another destination would doses to the pound. Fifty-two thousand probably make an appreciable reduction pounds of Epsom salts would mean in Satan's winter fuel bill. 9U SOUTHERN MEDICINE AND SURGERY Octob«r, 1922. Resection of Bones of Forearm for months for years. If ankylosis requires Ischemic Retraction of Flexor operative measures, they should be post- Muscles, poned until the tendency to hemophilia has been outgrown to some extent. In 2 Soubeyan corrected the cripplmg re- ^^ ^^^ ^^^^^^ several joints were affected, traction of the fingers in the boy of 10 ^^^^ ^^ 3 ^^^j^ y.^^^^ ^j^^^^. -^ another by shortening the long bones to corre- ^^gg ^j^g ^.^^j^^ ^^^^ ^^^ ^.j^j^^ shoulder, spond. He cut out a segment 2 cm. long, r^j^^ ^j,^^ disturbance was usually noted inside the periosteum, in both radius ^^ ^^^ ^^^ ^f 5 ^^ g^ ^^^ -^ j^^p^ ^^ ^-^^ and ulna but at different levels. No at- g^j^g j^jnt. In one case recurrence 30 tempt was made to suture the bone, the ^^j^gg j^^^j ^^^^ recorded. sutured periosteum cuff forming a sup- port. The plaster splint held the elbow Again the Poor Boy and Medical Edu- flexed, the fingers extended, in complete cation. supination. It was discarded the twenty- , ^ ., . , fifth day, and the functional use of the Long before the campaign began for fingers was regained and has been com- the improvement of medical education, plete during the eight years to date. The appeals were frequently being made for arm is 1.5 cm. shorter than its mate. ^he poor boy who wants to get a medi- cal education, and, as the higher en- Hemophilic Arthritis. France standards began rapidly to be adopted by medical schools, appeals of Montanari has had 11 cases and this kind were repeatedly commented knows of 3 more in which, without on by The Journal. The situation for known cause, or insignificant trauma, the poor boy today is better, if any- the knee, shoulder, elbow or wrist filled thing, than it was twenty years ago. with fluid, with ecchymoses in the vicin- It is true that medical colleges have in- ity. Slight fever followed, and the con- creased their requirements for admis- dition was chronic, the extravasated sion from a high school education to blood not being absorbed for months and two years of college work. The two then only incompletely. In some of the years of college work, however, are no cases the absorption was rapid and com- hindrance to the poor student ; there are plete in a few days, but a new hematoma many colleges which provide abundant soon developed. Atrophy of the limb opportunities whereby students of lim- above followed; in one case the middle ited means may work for all or part of third of the thigh measured 8 cm. less in their expenses. More time, indeed, is circumference than its mate. The roent- required, but these two years are well genograms showed nothing pathogno- spent by the student in securing a bet- monic. In 6 of the families the hered- ter preparation for his medical studies, itary transmission of the hemophilia It is true, also, that the cost of conduct- could be traced through generations, ing a medical school has been greatly four in one family. This hemophilic ar- increased during the last twenty years ; thritis represents an attenuated form of but, during the same time, the fees hemophilia, with a tendency to be out- paid by medical students have been only grown in time. Inherited syphilis was moderately advanced and cover only a known in 2 cases, and was suspected in a small portion of the cost. Even the third. No attempt at operative treat- slightly increased fees, however, are ment was made; extension was applied more than offset by the establishment to combat contracture, and the joint was of free scholarships and generous loan immobilized in plaster. The accumula- funds in the better grade medical tion of blood can be tapped at need, fol- schools. The opportunities for the stu- lowed by a compressing bandage and im- dent of limited means to secure a medi- mobilization, and ovarian or thyroid cal education have in no way been di- treatment can be tried, or Weil's method minished. As a matter of fact, the anx- of injecting blood serum every two iety which is still being expressed for October, 1922. MISCELLANEOUS 555 the boy who is poor in purse but not in with low standards of trade and traffic intelligence is not warranted by the in their souls; too many get in who are facts. Investigation discloses that not gentlemen to begin with and cannot many students of limited means are be made gentlemen to end with. Today found in all our high-grade medical the young physician too frequently feels schools, in which these students are en- compelled to ask his associates, "What abled in various ways to work their way do I get out of it?" when he might through. Meanwhile, it is the student better ask himself, "What am I putting of limited means who, as a rule, best ap- into it?" Greatly to be desired is a predates the value of both time and stronger effort to train the moral per- money. He is not enticed by the pre- ception of medical students. They must tentious statements of low-grade medi- be inspired toward a high-minded es- cal colleges, but usually selects the bet- tate. In the speech and bearing of ter institution. It is quite evident, graduates of certain medical schools can therefore, that the improved standards be recognized just exactly the outlook of medical education are not hindering on life and the regard for our profession the student who is poor in purse from held by their teachers. It is an uncon- obtaining a medical education.— Journal scious percolation. The fine sense of A. M. A., August 19, 1922. intuitive right-thinking and truth-lov- ing can shine through both precept and The Real Thing in Medicine. example. Morals cannot be legislated The minimum requirements for a into people; but the ideals can be edu- career in medicine are a preliminary cated into them. education, four years in a medical school, and a license to practice. While p„*on^:„«. 4u^ i? ^ * a • ^ u* 1 • ^, ' , • T ui t-xtending the Front Against Malaria. these requirements are indispensable, they are by no means sufficient, says Despite the economic depression Hubert A. Royster, Raleigh, N. C. ^^'^^ch hit the Southern States with ex- (Journal A. M. A., Aug. 5, 1922). Three ^^eme severity, the fight against ma- higher attributes stand out as real ele- ^aria was maintained and steadily ex- ments that make for a successful phy- tended. sician; without these, real success in "During the year 1921 a major at- medicine is impossible: brains, culture tack against malaria has been opened and character. Brains are the alpha along the entire front, including town, and omega of the man of medicine. Cul- village, and the open country. The unit ture is refinement, accuracy, poise, re- of operations is the county. Malaria sourcefulness; it is not effeminacy, control is undertaken as a part of the weakness, conventionahsm, impractica- permanent county health schemes; is bility. Detracting not one whit from supported by state, county, and local the appeal for better mental equipment, funds ; and is under the direction of the it appears even more timely to empha- county health officer, size the greater need for moral qualifi- "All available measures are employ- cation in the physician. The character ed, each receiving emphasis according of a physician is his most priceless to local conditions. In Alabama, where property. It is what he stands for and an energetic sanitary engineer is co- whom he stands with; it is his attitude operating with the health officer in a toward life; it is "what God sees him group of five counties, mosquito control do in the dark." Truth is the goal; it is being extended to rural communities, develops character, and character tells The top minnow is the principal agent in one's work. Too many are entering here. The farmers are maintaining the medical profession without good minnow ponds from which mosquito- working consciences, without a keen ap- breeding waters may be easily stocked preciation of the difference between with fish. In the Mississippi delta, on right and wrong; too many are coming the other hand, where mosquito control into an honored and honorable calling is less feasibly, anti-mosquito measures &56 SOUTHERN MEDICINE AND SURGERY October, 1922. Table of Contents for October, 1922 Original Communications, Is th€ State Hospital Doing Its Duty ? by Albert Anderson, M. D 501 Emotional Instability as it Relates to Deliquency, by Wm. A. Newbold, M. D 509 Hyper-Thyroidism and Hypo-Ovaria, by Addison G. Brenizer, M. D 514 Non-Surgical Biliary Drainage by Heath Nisbet, M. D 518 The Tonsil Question in Children, by L. N. West, M. D 521 Blood Pressure in Pregnancy, by J. N. Upshur, M. D 524 Carcinoma of the Cecum, by R. L. Gibbon, M. D., and J. W. Gibbon. M. D 526 The Relation of Modern Dentistry to the Practice of Medicine, by Guy R. Harrison, M. D 530 Editorials A Medical Democracy 534 Department Editors Medicine, W. B. Porter, M. D 53& Surgery, A. E. Baker, M. D 537 Gynecology and Obstetrics, Robt. E. Seibels, M. D 539 Mental and Nervous, J. K. Hall, M. D 542 Eye, Ear, Nose and Throat, J. P. Matheson, M. D 543 Orthopaedics, Alonzo Myers. M. D 543 Roentgenology, Robt. H. Lafferty, M. D.-_544 Pediatrics, Frank Howard Richard- son, M. D 545 Clinical and Professional Notes, J. A. Hodges, M. D 545 News Items 547 are not neglected where conditions favor but greater emphasis is being placed on sterilizing quinine treatment. In all counties where the work has been undertaken the people are being taught fo screen their houses as a protection against flies and mosquitoes. The standard quinine treatment for those who have malaria is provided at con- venient points and its use is being stim- ulated by systematic education. This country-wide effort is being undertaken not as a brief intensive drive, but as a slow, steady campaign to be continued over a period of years." Diseases of the Skin, by Henry H. Hazen, A. B., M. D., Professor of Dermatology Medi- cal Departmnet of Georgetown University, Professor of Dermatology, Medical Depart- ment of Howard University, etc. 608 Pages, 241 Illustrations— C. V. Mosby Co., St. Louis. $7.50. This book has been written to strike the happy medium between the very large and exhaustive treatises on the subject and the condensed quiz compends. It is directed es- pecially to the medical student and the gen- eral practitioner. The author describes quite fully the common diseases but pays less attention to the very rare ones. Especially does he discuss those skin conditions which are now attracting the greatest attention. This second Edition has been practically en- tirely re-written and especial emphasis has been put upon the X-Ray and radium treat- ment of skin pathology. Southern Medicine and Surgery Vol. LXXXIV CHARLOTTE, N. C, NOVEMBER, 1922 No. 11 this statement will be accepted if there is borne in mind the long years that this THF MFSSArF OF P^vrHTATRY ^^^^^^^ remained dormant, the very IHL MESisAGb Ot FbYLHlAlKY ghort time since it has been awakened, TO GENERAL MEDICINE. ^"^ ^^^ great strides it has made in that short period. In fact scientific psychia- By William A. White, M. D., ^^^ ^^ a medical specialty of equal dig- nity with the other medical specialties Washington, D. C. f^om the point of view of content and methods is a development almost wholly The path of science leads from the within the personal knowledge and ex- region of the known into the region of perience of the present generation, the unknown ; the methods differ in the In fact modern psychiatry has devel- different sciences; but the material oped so astonishingly, has attracted so dealt with often consists of facts of ex- many skilled physicians and profound perience, ideas, beliefs, customs, for- thinkers, and created such an extensive mulations of all sorts which have come literature that the large majority of to be accepted but which the scientist medical men, of necessity, realize very re-subjects to scrutiny from new angles inadequately its accommplishments. I and discovers hitherto unsuspected shall not endeavor to outline what these components and correlations. have been. I shall only attempt to give At certain periods in the history of ^o" briefly some thoughts which the knowledge matters have remained at a study of psychiatry has brought into standstill, a well defined set of formu- being and which seem to me to be of lations has been accepted as final and ^^eat significance for general medicine, the main effort was expended in sup- I am aware that many of these thoughts port of what was generally accepted, are in the nature of hypotheses only and This has been true in our own time of «« i" ^heir varied implications may, m such disciplines as sociology, economics, ^any instances, not prove to correr and ethics, and was glaringly the case ^pond to the facts as these will develop, in the past with religion and theology, ^ut I have a great respect for hypothe- rp , . • J r . ■■ ses as tools of progress and I can con- Today we are in a period of rapid ^^ ^^ ^^^^^^ ^^-^^^-^^ ^j^ ^^an change, one outstanding feature of ^^ ^^.^^ ^^^ ^^ speculate, for I be- which IS that there IS little respect for j.^^^^ ^^^^ .^ .^ ^^^ ^^ multitudinous the past or for authority. Science and ^^ ^^^. ^^ ^^^^^ ^^^^ truth is scientific methods and scientific thought ^^^^j^, ^^^^^ ^^^^ ^^ are more prominently in the foreground ^^^, ^^^ ^f ^^^-^^ ^^ ^^^t I than ever before and the ideal of pure ^^^^ ^^ j^^ ^^ ^^^ ^ q^^^^j^^ ^^ich science IS truth and truth only and the ^^ ^^^ ^^^^ ^^ ^^^ ^^^^^ ^^^ter. faith of pure science is that truth will ^^^^ .^ ^.^^, jf^ ^^ physician, your invariably justify itself and in the end ^^^^^^ ^^ ^ patient's symptoms indicates be a more valuable possession than any ^^^{ ^^ jg suffering from nephritis, or form of error cardiac dilatation, you are expressing This scientific spirit has invaded the y^^^ conclusions in terms of the func- field of psychiatry. Perhaps as a psy- ^.j^j^g of separate organs, the kidney or chiatrist I may be prejudiced, but I feel ^^^ heart, and your investigations and that in no department of medicine has formulations are wholly within the progress been so rapid and I believe realm of physiology. The investiga- 558 SOUTHERN MEDICINE AND SURGERY November, 1922. tion of the functions of any particular the bodily structure of man can be part of the organism is a problem in traced back in an uninterrupted series physiology. Now, per contra, if we see to the simple amoeba so can the psyche ja man go through a certain series of of man be similarly traced back to sim- motions, for example, he walks into a ilarly simple origins: it means, in short, bake Fhrr,, lays down a dime, and re- that the psyche is as old as the soma; ceives a loaf of bread, we can no longer that in the very beginnings of life the adequately formulate what we see in foundations were laid down that later terms of functions of the parts of his developed into man with the two-fold organism. True, we can describe the aspect of body and mind; it means that contraction of the various groups of psychology, quite as truly as physiol- . muscles used in walking, in reaching ogy, is a biological science, into his pocket for money, in speaking This concept, that the phylogenetic to the baker, etc., but no addition of all histories of the psyche and the soma these part reactions will give an ade- are contemporaneous, that mind and quate description of what actually took body, as such, are but different aspects place. The question heie is not, What of life, itself, is, I beheve, the most preg- is this or that muscle or other organ nant concept which psychiatry has come .doing? but, What is the man doing? to realize and which it is slowly forcing And the answer is in similar terms, He to be generally recognized. Its signifi- is buying a loaf of bread. Here the sub- cance for general medicine lies in the ject of the inquiry is not some part of fact • that, almost wholly, medicine is the man but the man himself — the man occupied with the problems of the body, as a whole. And now the point I wish the soma — and it has devolved upon to make is that it is only when we come psychiatry to point out the one-sided- to deal with the reactions of the total ness and consequent danger of this re- organism that we are in the realm of stricted view-point. And the reason psychology as distinguished from physi- why psychiatry has come to this conclu- ology. I would not pretend to attempt sion is that it alone, of all the medical to define mind in its ultimate nature but specialties, deals with total life re- only from the phenomenal point of view, actions, that is, we can define mind only by indi- The implications of mind as a total 'eating what sort of phenomena are life reaction are these : the mind by its mental, by describing a certain group ideas, ideals, feelings, emotions or other of phenomena which have some char- symbols, represents the tendencies of acteristic in common and then assum- the individual as a whole, the objects or ing that back of that common charac- goals which are desired or wished to be teristic there is a mind. The common attained; the body consists of the ma- characteristic of the group of reactions chinery by means of which these de- to which the qualification mental is sires are attained. The man who wish- properly applied is that they are total ed to buy a loaf of bread had at his dis- reactions, that is, reactions of the indi- posal the motor apparatus of his limbs vidual as a whole, as a unity. which carried him to the bakeshop; the This point of view is fundamental and motor apparatus of his larynx, with you will see implies that every living which he expressed his wish to the organism does certain things which may baker, etc., etc. The body is but a be considered as psychological in char- means, the ends receive their only ex- acter. Not only may a man purchase pression in the realm of the psyche, are a loaf of bread but an amoeba may expressed only in the symbols of Ian- stream towards a food particle. This guage, of ideas, of feelings, of formu- does not mean that the amoeba has any- lated volitions. thing that even remotely corresponds to Now the further implication seems the mind of man any more than that its obvious, namely, that the wishes as ex- bodily structure remotely corresponds pressed thus, symbolically, are depend- to that of man, but it does mean th^t a3 ent upon the organic make-up, upon the November, 1922. ORIGINAL COMMUNICATIONS 559 nature of the body. The ideas are con- have my patients happy than any other ditioned by the bodily, the organic con- one thing." Now I ask you, What is all stellation. The amoeba cannot desire a this if it is not psychotherapy ? although filet mignon, it can only desire to stream I grant you it is not generally so thought towards certain particles that it has a of. chemotropic attraction for: the congen- Without proceeding further in this itally blmd man cannot have desires ex- particular matter let me concretely for- pressed m visual terms. mulate what I tried to get over by this Similarly, though perhaps not so ob- illustration. First, that there is a psy- viously at first sight, the man crippled chogenic component in pulmonary tuber- by the loss of an arm or by the destruc- culosis, a disease which is ordinarily tion of a special sense organ lives in a thought of as purely organic in type, different psychological world of desires and second, the importance of the psy- and efforts than one not so handicapped, chogenic component as well as its ex- To elaborate this thought somewhat istence is testified to by the psycho- more specifically in the realm of symp- therapeutic aspect of the treatment, tomatology, take for example the situa- So far I am hopeful that you follow tion in pulmonary tuberculosis. This me. I shall now plunge a little deeper disease is thought of as being, in part into the realm of speculation which is so at least, due to lack of outdoor life, lack inviting to many but which I know oth- of an adequate supply of fresh air, a se- ers have little stomach for. For these dentary life and the like. Now I would purposes let us consider such a disease call your attention to the fact that these as diabetes mellitus. We are familiar factors are all dependent upon the hab- with the correlation of the emotions its of life of the individual and these with the mobilization of sugar so that habits are matters of the mind. An in- we might expect to find our diabetic door instead of an outdoor life means patient suffering from a continuous that the out of doors does not attract bombardment of violent emotions such the individual strongly, he does not care as fear, hate, anxiety and anger. But this for that sort of thing: it means also, in surely is not the case if we accept our many cases, and especially when accom- patient, so to speak, at his face value, panied by a sedentary habit, that the He does not appear to be so involved individual is not a good mixer, he with- nor does he tell us of any such emotional draws from social contacts, he lives by experiences. But here is just the rub. preference within himself, in the termi- Why should we be content with appear- nology of psychiatry he has a "shut in" ances only? I am reminded of the his- character. tory of anatomy. It took many years Now when the physician comes to and great courage to overcome the treat such a patient. What does he do? prejudices that stood in the way of the He tries to modify his habits, he tries dissection of the human body but until to get him to change his way of living this was finally accomplished. What pos- so that he will spend more time out of sibly could be known of its structure? doors, away from super heated rooms: The analogy here of our knowledge of he tries to get him to change his seden- the body and our knowledge of the mind tary, desk habits for a more hygienic is close. We can as little hope to learn regime. Not only does the physician try the inner facts of mind from our ordi- to accomplish this, which, I will call nary superficial contacts and observa- your attention to again in passing, is tions as we could hope to learn the purely an appeal to the mind of the pa- structure of the body from looking at its tient, but he tries to secure his cooper- skin surface. Not only is it true that ation, not only his formal cooperation, we must develop an anatomy of the but he tries to get him to really enjoy mind by analogy to the anatomy of the the new way of living. One of the body which we must come at by a meth- foremost specialists in tuberculosis in od that permits us vision beneath the this country said to me, "I would rather surface, but, and here is the aspect of 560 SOUTHERN MEDICINE AND SURGERY November, 1922. the analogy of supreme importance, we only be disclosed by a special techni- must develop an embryology and a com- que. parative anatomy of the mind for have To reduce what has been said up to we not said that the psyche is as old as this point to a simple formulation : the body and if that be true it must also Organic disorders have their psychol- be true that during the ages in which ogic as well as their somatic symptoma- it has been developing to its present tology. This, reduced to its simplest state ic has developed structures quite terms, is the gist of the message, as I as complex as those of the body and take it, that psychiatry has for general which can only be understood, like those medicine. of the body, by the unravelling of their The carrying out of the implications past history. These developments are of such a formulation, consciously or already represented by departments of unconsciously, is responsible for efforts psychology. Embryology has its coun- that are being made in many directions, terpart in genetic psychology, and com- the results of which are appearing now parative anatomy its counterpart in quite frequently in the medical and psy- comparative psychology, while paleon- chological literature. One of these ef- tology is also coming to have a counter- forts, which harks back in its origins part in the newly developing paleo- so prominently to the times of Hippo- psychology. And finally the method of crates and Galen is the effort to divide anatomy has its counterpart in the man into certain types based upon a method of psychoanalysis, a method of general and more or less obvious phy- dissection which has to be carried out sical make-up and carrying with that during life for with death the mind es- make-up fairly well defined mental capes us. traits. This effort has had a varied his- Now to come back to our diabetic pa- tory but it appeared prominently in tient. The mere fact that he does not France during the war as a means for show violent emotions to the ordinary allocating the army personnel to the methods of observation and inquiry is different branches of the service. Brief- no more evidence that he is not their ly» the results were as follows : host and suffering from their conse- (1) The abdominal or digestive type, quences than the fact that his cutaneous if pure, has a large abdomen, jaws, a surface is free from blemishes is proof face slightly pyramidal; is best fitted positive that he cannot have a pan- for certain vocations, needs its own creatitis or anything else for that mat- medical treatment, etc. This type is ter that could hide beneath the skin more dependent than any other, both surface. for health and efficiency, upon dietary What I am getting at must now, I ^^"ditions. Food and drink must be hope, be clear. If the organism is ^^bundant and regular; while there is a unity as I have indicated, if mind is ^^"1^ P^^I ^^ ^^^' "P against hunger, but a name for the functioning of the T Tu ^^ ^'f °" 1 ^/' '^'' unity as a whole, then it must needs be !l^^"^ ^^^' ^1"^°^* ^"^^^l^f ^^ ^,f that whenever there is any serious or- '^ '\^^' excellence for defence. Its n-ori,-« ,-v„T^i,,^w,^v,^- -P 4. i. greatest power is to repel attack or in- ganic involvement of some part or parts • -fl • 4.- j. ^ ^- j „ , - ■ j_-, vasion. Its instincts are protective and of the organism there must be some sort conservative. Assaults upon home, pos- of expression of the trouble resulting in sessions, camps, stores, and supplies the symbols at the psychological level, make such a soldier the one whom the in other words in the mind, the psyche, invader has most to fear. In some sense The fact that such expression is not in b^;« childlike Glandular functions are _ . •, n -,. J. ., ., .,.^ well developed. The ribs are high, the evidence for discarding its possibility, ^^bilicus low; the intestinal trak is it needs to be looked for, searched out longer than the average, etc. by the use of special methods. If it lies (2) The respiratory type has a deep in the unconscious, as we call it, it can chest, body long, especially the thorax; November, 1922. ORIGINAL COMMUNICATIONS 561 the face is widest across the middle impunity. Their best medicine, if ill, third, including nose and ears, and the is a more active regimen. They are less head tends to taper slightly above and prone to inertness than the digestives; below. This type needs most air, suffers less to excitement than the respiratories. most if it is defective or deficient ; dis- If need be, they can plod on without en- eases are best cured by change of cli- thusiasm, with patience and persist- mate, for their energy is very depend- ence, for they get more pleasure from ent on the oxygen they breathe. They their own active effort, even if they can- best endure changes of both tempera- not see its purpose. Long trench con- ture and altitude ; are susceptible to air finement is harder on them than for the too dry or too cold ; best bear exposure digestives, but less so than for the res- to wind and weather and love to brave piratories. To do their best, they need them ; their responses to emotional a leader more than the respiratories, but changes are registered in those of res- less than the digestives, who have less piration. They love exercises that ex- initiative. They endure hunger and pand the lungs, for their build needs bad air, but cannot sustain long in- much more aeration than does that of action, which sours their temper. They the digestives, though they can get on live to act and always want to be up and with far less rations. In war they excel doing. The fatigue point is high but if in aviation and mountain work. They they go far beyond it, the neuro-mus- are best for attack, loving the dash and cular system may collapse, although in rally. They crave excitment, adven- general they recuperate well. In native ture, and pine in mechanism and mo- intelligence they are between the two notony; tend to buoyancy as the diges- preceding classes. Their hair is often tives do to depression. Long confine- at right angles at its point of insertion ment in the trenches is far harder for in the skin. The neck is long, muscular them than for the digestives, although and large, though not as large as the the latter excel in patience. Their forte digestive's. They are often dolicho- is scouting, spying, pioneering, adven- cephalic, and need to be hard up against turing, initiative. They can bear soli- reaJity. tude but are also prone to conviviality. (4) The nervous or cerebral type has This type is common among the Nordic a head broadest at the hat-rim, perhaps races ; they have much in common with tapering downward, so that at the jaw the old sanguine, are sometimes prog- level it may be a little weak and small, nathic, and often have unusual vocal de- The body lacks the marked traits of velopment. This broncho-pulmonary the other types, is not large but very diathesis inclines them more to country variable in form and proportion; but the than to city life. brain dominates other organs and func- (3) The muscular, athletic type is tions more. Here are found the intel- characterized by long, strong limbs, a lectuals whose well or ill being and effi- body not very long but well developed, ciency depend on their state of mind, with neither the abdomen nor the thor- Their diseases and cures are more mind- acic measurements predominating; made, so that the conscious and uncon- with a head tending to cubical form; scious psyche determine health and ac- facial diameter more nearly equal in tivity, and they can do and be what they each of the three levels. Their mus- feel they can. They are most versatile, cles are of greater relative weight than less dependent on food, air, or exercise any other class. Such people must have than the other three types ; most adap- abundant exercise and decline without table to any kind of life or branch of it to depression and ailments, not only service, attack or defence; can wait or rheumatic, but digestive, circulatory, fight, adjust to new conditions in the and nervous. They are at their best environment quickly ; often love the new when they dig, lift, carry, run, march, and strange. Even if they seem frail throw, and thrive on an amount of work they can pick up and also develop per- which no other type could sustain with haps to a surprising degree. They re- 662 SOUTHERN MEDICINE AND SURGERY November, 1922. spond to everything that effects the re-examination of old concepts and so emotional tone, the morale, group-spir- discovering new truths. Let m_e hastily it. Hence religion, recreation, social mention a few. intercourse, friendly rapport with offi- Epilepsy was long considered as a cers, comrades, home, helps ; so that the purely physical, generally as a toxic esprit du corps in camp is what this cer- disease. A re-examination of the con- ebral or neural type makes it. One of cept in the light of facts learned else- its chief traits is the power to summon where led not only to the discovery that reserve possibilities, on emergency, to there were a great many things which unfold "the higher powers of man." had been included in this one concept They can sometimes perform prodigies, that were of varied nature, but led also but pay dearly for temporary excellence to the concept of a so-called essential when their reserves are used up. Col- epilepsy which, as a disease, was a lapse is more delayed, but if it comes, total life reaction, and which, therefore, more prolonged. They prefer the city ; contained a large, important, and potent intestines are short; they are best in psychogenic factor. Whether this psy- meeting emergencies. chogenic factor is primary, whether it This is an attempt, you will note, to is secondary and dependent upon an or- define the types of individuals from ganic defect or disorder, or whether the their outward physical form in terms of two factors, psychic and organic, are but their fitness for the different varieties different aspects each of the other are of military duty. Similar efforts have questions that can be asked about every been made from other points of view disease in which a psychogenic factor and in psychiatry particularly from the is operative and the question, probably, point of view of liability to certain will have to be answered differently in forms of mental disease. In these ef- different cases. In any case we may be forts is seen an overt admission of the quite sure that we at present know very point of view I am setting forth, name- little about those psychic symptoms ly: that the psyche and the soma are which are not obvious and on the sur- not separate entities but different as- face but correspond to organs that have pects of the same unity — the organism a long developmental history hidden in as a whole. their complex structures While such a point of view as this has With reference to this last matter, for been given sporadic expression from instance, let us take for illustration, our time to time through the ages, still, concept of sex. We know a good deal until recently, the psyche has been, about the differences in sex but where, and still is very largely for that matter, in our concept are we going to place the treated as something different, a thing fact of the different incidence of many apart from the body, in quite the same diseases in the two sexes. We can at- way, though much less crudely, than it tribute the prevalence of Huntington's was thought of in the middle ages as chorea in men to sex linked inheritance; leaving the body at death so that a we can hitch up the prevalence of window must be left open in the room chlorosis in young women with the men- where a dead body lay to give egress to strual function ; but how are we to ex- the soul when it should have left the plain the preponderance of paresis in body and was seeking other regions. males, of Sydenham's chorea, arthritis This old concept of the soul has had deformans, and exophthalmic goitre in therefore, to be re-examined, and I have women, and when we read in the sta- indicated to you some of the lines of ^istics that the mortality in such dis- thought that have resulted from such eases as smallpox, measles, scarlet a re-examination fever, diarrhoea, phthisis, and diseases In this way does scientific thought °^ ^^^ ^^^^°"« ^"^ respiratory system advance, by the re-examination, in the ^s greater m males our concept of sex is light of new facts, of old concepts, quite inadequate. The psychiatrist, Psychiatry is advancing now by the however, in his probing of the depths November, 1922. ORIGINAL COMMUNICATIONS 563 of the psyche bids fair to throw some that old concepts must be re-examined real light on this situation. and second, that psychiatry has some- I am reminded here of an incident in thing to offer in ajiy such re-examina- my experience some years ago. In my tion. visit to Bellevue Hospital in New York We know only too little about such City my attention was called to the fact large matters as sex, menopause, sen- that the psychoses in the alcoholic ward ility, arteriosclerosis and the part they showed a much greater variety among play in conditioning various diseases, in the men than among the women. It fact we know too little about every- occurred to me that the explanation thing, and the thing that I wanted to might be something like this : say was that psychiatry had something Of the two sexes the female repre- to offer in unravelling these complex sents more nearly the fundamental, problems. basic requirements of the species, while For years man has only too often the male, stationed, as it were on the been considered by the physician as if firing line of biological adaptation, rep- he was all body and in considering him resents the variant. If this is a fair from this point of view certain appar- statement of the facts then the wider ently unsolvable problems have develop- variety of psychotic reactions from alco- ed. May not the key to the solution of hoi in the male can be readily under- some of them at least be found in this stood. long neglected region of the psyche? The predominance of depressions in Is it nou time that the mind should have later life in woman can, it seems to me, a place in the physician's consideration be in part explained in a similar way. of his patient every whit as important Her reproductive life comes to an end as his body? in the fourth decade, the gonads ceasing to function largely perhaps because at this age period the mechanical difficul- r»ovr>urwc3T?c' a cerkr^T a rrc^rk ties to labor have accumulated suffi- THE PSYCHOSES ASSOCIATED ciently to make this function exceed- WITH PERNICIOUS ANEMIA. ingly dangerous to life. Not having ac- quired other interests on her way o. B. Darden, M. D., and J. K. Hall, M. D., through life, being preponderantly the westbrook Sanatorium, agent ol the species niterest, m tact al- most exclusively so to her own personal Richmond, Virginia, detriment, she has nothing to turn to, no outlet for her creative tendencies Case Report: C. L. G., white, male, when the child-bearing period comes to telegrapher, 42 years of age. an end. The menopause spells for her Family History: The mother, who is the end of her vital life interest. It is living at the age of about 70 years, was quite different with the male. Not only treated at least once in a state hos- does his gonadal function continue I'ital for some mental disorder. The longer but he maintains other interests father, who died at about 60 years of with which he can carry on indefinitely, age of what was probably kidney Perhaps the preponderance of paresis trouble, was somewhat alcoholic as a in the male is dependent upon the psy- young man. Otherwise the family his- chological, the cerebral stress that is in- tory is unimportant, cident to these multitudinous interests Personal History: The patient as a with their respective emotional drives, young man was robust; there was an Carrying out the will of the species is occasional mild alcoholic spree, but foi* perhaps not mentally at least so stress- the past three or four years he has not ful as pushing ahead upon some indi- touched whiskey. He smoked cigar- vidually worked out plan. ettes to excess. Enlisted in the army I have just touched upon these two or as telegraph operator at the age of 18 three points to indicate two things, first, and lived, among other places, in Alas- 664 SOUTHERN MEDICINE AND SURGERY November, 1922. ka and the Philippines, Is married, mucous membranes were normal. There The first pregnancy resulted in the birth was slight evidence of receding of the of a child dead at term; the second gums, but no evidence of active infec- pregnancy terminated as a miscarriage tion about the teeth. The teeth were at about two months. During the fall in a fair state of preservation. The of 1921 while working as a telegraph tonsils were apparently in normal con- operator he slowly became depressed dition. The thyroid was not hyper- and developed delusions. He believed trophied. The apex of the heart could his life had been a failure; his early not be located by inspection or palpa- whiskey drinking was the cause of all tion in the recumbent or upright posi- his troubles; he lodged various accusa- tion, but when leaning forward it was tions against himself ; he read the Bible located in the fourth interspace near much, but found only self condemnation the left mid-clavicular line. There was in it ; people did not treat him right ; his no increase in the transverse diameter own sisters did not sympathize with of the organ. The cardiac sounds were him (and his wife thinks they did not clear and distinct and free from mur- understand his condition, but thought murs and the muscular tone was ap- of him as no account) ; the roughness parently of good quality. The pulse was on the backs of his hands meant some of good volume and force, regular, but terrible disease. Sleep was poor and his persistently rapid, rate 52 to the 1-2 appetite was not good, though as a rule minute. The radial arteries were pal- it had been good. He is, as a rule, con- pable but not unduly hardened. The stipated. heart rate increased on slight exercise, Because of his mental condition he but returned to normal within normal was sent to the State Hospital at Wil- limits. The systolic blood pressure was liamsburg, where he remained for about 148 ; the diastolic 98. Liver dullness was a month, after which he returned home not increased nor was the organ pal- apparently well and resumed his work, pable. The spleen was not palpable, which he kept up continuously until The abdomen was normal. In the left the early part of January, 1922. At this inguinal region there was a small scar time he thought people were watching as the result of an operation in 1905 him carefully ; the thought that his pro- for a bubo which followed a genital sore bation period at the State Hospital was which the patient claims he was told about to expire weighed upon his mind, was a chancroid. No genital scar was which fact has probably helped him to visible. think people were watching him. He Neurological Examination : The pupils again became sleepless ; his appetite has were slightly dilated, but equal. Both been poor ; and he has been greatly con- were uneven in outline and immobile to stipated. light, though reaction during accommo- He was first seen on January 6, 1922. dation was good. There was no tremor Physical Examination; Physical ex- of the outstretched fingers and no loss amination revealed a well-nourished, of muscular power of the upper extre- well-developed white man whose ap- mities. All tendon reflexes were nor- parent age and actual age were the mally active except for a trifling ex- same ; he lay quietly in bed, apparently aggeration of the right tendo Achillis. perfectly comfortable, though perhaps There was no Oppenheim, Gordon or somewhat apprehensive; he did not Babinski; no ankle clonus. The super- look to be acutely sick and cooperated ficial reflexes were normally active, thoroughly during the examination. Station and gait and coordination were The expression of the face was rather normal. Sensation was undisturbed, blank and masked. The eyes showed a Mental Examination: Memory was slight tendency to exophthalmos. The not affected ; orientation for time, place sclerae were rather muddy, but show- and person was good; comprehension ed no definite icteriod tint. The tongue was undisturbed. He seemed to be was red and clean and tremulous. The somewhat confused and his delusional November, 1922. ORIGINAL COMMUNICATIONS 565 ideas were disconnected, vague and un- the examination of January 6, 1922. At systematized. He was self-accusatory, this time he was decidedly anemic exaggerating the bad things of his past though the face was somewhat tanned, life. As an insight into his mental giving a rather peculiar appearance, condition the following is given in some Outside the tanning, however, there was detail : He says while at work on what more or less of the lemon tint of perni- was called a fast wire something seem- cious anemia. The sclerae showed a ed to hold him back. He realized this definite icteroid appearance. The tongue was the light on his left side, and he was fairly clean, but showed a number began to become more or less left-hand- of beefy red areas ; there was slight ed. Before this time he read rather ex- tremor. The mucous membranes had tensively a book called Power of Will, become pale and anemic. The lips were Following this in all his efforts there pale. The lungs were normal. Exami- was something pulling at him and ap- nation of the heart revealed nothing ab- parently keeping him from progressing normal. The blood pressure had been in his work. After leaving the State reduced from 148-98 to 114-78. The Hospital he was able to return home to pulse was of only fairly good volume and his duties and while at work a light force, rate 83 to the minute. Neither which showed him he was in the wrong the liver nor the spleen was palpable, came into his eyes; the light was too Neurological Examination: The un- bright. People at home had little to evenness of the margin of the right say to him because they expected a pupil was somewhat more marked, oth- confession from him and he did not erwise the pupils were the same as re- make it because he did not know what corded in the former examination, had happened. There was a positive Romberg. The pa- Laboratory Examination: The Was- tient was unable to stand on one foot serman was negative on both the blood with eyes either opened or closed. Co- and the spinal fluid. The spinal fluid ordination was normal. The muscular showed no increase in globulin ; 3 cells power of the right hand was somewhat per c. mm. There was very slight in- better than in the left. Gait was nor- crease in pressure of the fluid. mal. The deep and superficial reflexes The urinalysis showed: Amber col- were normally active. Sensation was or; clear, acid reaction, specific gravity undisturbed. Vibration sense as tested 1027, trace of albumen, occasional with a tuning fork was normal, hyalin cast. Mental Examination: The mental Progress: After showing practically status has remained practically as at no improvement for about a month, the the time of the last examination. Be- patient was again sent to the State fore his birth there was some trouble Hospital, where he remained until July between his father and mother about 1, 1922, when he was transfererd to which he was not told; his married sis- Westbrook Sanatorium. The patient ter had taken sides with his father and stated that during most of his stay in had turned completely against him, the State Hospital he was depressed, following him, taking advantage of him worried about his physical condition and and causing his ruin. His wife had at about his spiritual condition and about one time been against him but now she the welfare of his wife and other rela- is his friend. Friends of the family fives. He stated that he did not work have taken sides in the controversy, while in the asylum, that he was out He had various religious ideas; he be- of doors very little, his appetite was not lieved he was condemned ; and he very good, and he feels that he has not thought the doctors shunned him be- improved in recent months. He com- cause he smoked cigarettes, plained a great deal of muscular weak- Laboratory Examination: The blood ness. Wassermann was again negative on July On admission the physical examina- 6, July 29, and on August 1, after a pro- tion revealed few details different from vocative dose of .2 gram of Neosalvar- 566 SOUTHERN MEDICINE AND SURGERY November, 1922, san on July 29. The blood sugar was two hours 62%. Numerous examina- .10% ; blood urea 55 mgm per 100 cc of tions of the urine showed the color vary- blood. On July 5, a blood examination ing from amber to watery, acid reac- showed: Leucocytes 6,000 per c. mm; tion, specific gravity varying from 1,004 hemoglobin 60% (Sahli) ; 55^0 (Dare), to 1,020, sugar negative, albumen pres- The stained smear showed: Polymor- ent at times in traces; urobilin was phonuclear Neutrophiles 59%; Small present. Misroscopic examination re- Lymphocytes 40% ; Large Lymphocytes vealed no abnormal morphologic ele- 1% ; red cells 2,000,000. The red cells ments. showed marked variation in size and Progress: The patient has retained shape; no nucleated red cells were his weight, varying from 114 to 118 found. Blood examination on July 8, pounds, but he does not seem to be showed: Leucocytes 6,000 per c. mm; so strong physically. The tongue has Polymorphonuclear Neutrophiles 60%^ ; varied from a fiery, beefy red appear- Small Lymphocytes 34%, ; Large Lym- ance to one of pallor with occasional phocytes 4% ; Eosinophiles 2%.. Macro- red splotches. During his stay in the cytes and microcytes were present. Sanatorium he has apparently been There was some stippling of the red comfortable and satisfied. At no time cells and slight polychromatophilia. has he been irritable, or exhibited ill The hemoglobin was 557o ; red cells temper, but on the other hand he seems 2,200,000 per c. mm; color index 1.3. to be always in good humor. He does July 28: Leucocytes 5,000 per c. mm; not mingle freely with other patients Polymorphonuclear Neutrophiles 50% ; and spends his time either in his room Small Lymphocytes 46%, ; Large Lym- or sitting quietly in the yard. He has phocytes 4%. Numerous macrocytes not been apathetic or somnolent, but and microcytes and poikilocytes were his inactivity is apparently due to phy- present. There was some polychroma- sical weakness. While preparing to re- tophilia and occasional stippling of the turn to the State Hospital he thought red cells ; one megnaloblast was found ; he was being taken away to be killed, red cells 1,530,000; color index 1.8; In recent years it has become a well September 2, the blood showed: Leu- established fact that people suffering cocytes 5,600 per c. mm ; Polymorpho- with pernicious anemia may seek re- nuclear Neutrophilis 47 per cent; Lym- lief of the physician because of dis- phocytes 51%; Eosinophiles 1%-; Baso- orders of the central nervous system, philes 1%. Microcytes, macrocytes. As a rule these early symptoms, par- poikilocytes, polychromatophilia and asthesias and anaesthesias, indicative granular degeneration were present ; of central nervous system involvement, red cells 1,000,000; blood platelets 160,- are referable only to the cord, and are 000 per c. mm; hemoglobin 33% ;color manifested clinically by burning, ting- index 1.6; coagulation time 3 minutes, ling, numbness, and other peculiar sen- September 16 : Fragility test for red sations especially in the upper and lower cells showed hemolysis began in tube extremities; rarely these may appear containing .5% salt solution and was as characteristic pathological findings completed at .35%. On July 12, a frac- in combined sclerosis and degeneration tional estimate of the gastric juice re- of the posterior and lateral columns, vealed an absence of free Hcl. and a Not only may cord symptoms precede total acidity ranging from 10 to 20. those usually looked for or expected in July 17: An examination of stool show- the disease, but not infrequently they ed no ova or parasite. Another stool ex- cause great difficulty and some confu- amination on August 4, showed no ova sion in diagnosis, both in simultating or parasite and no occult blood. On July primary diseases of the cord, and be- 28 the kidney as estimated by the cause the typical blood picture of perni- phenolsulphonephthalein test showed an cious amenia is often absent for months output for the first hour of 50% ; for or even years after the nervous symp- the second hour 12%; totaling for the tom? appear. November, 1922. ORIGINAL COMMUNICATIONS 667 The literature on this phase of the plaint in penicious anemia in addition to subject has reached such tremendous those enumerated above, are progressive proportions that any attempt at a com- muscular weakness with subsequent in- plete review in this report would be ability to continue accustomed work, futile. As early as 1884 Lichtenstern' palpitation, shortness of breath, recur- described two cases of pernicious anemia rent sore mouth and tongue for varying with spinal cord symptoms, and he be- periods of time, with or without other lieved the anemia to be the result of the gastro-intestinal symptoms, such as so- degeneration of the nervous tissue. Two called indigestion and recurring diar- years later Lichthiem- advanced the rhea. These facts voluntarily stated opinion that in cases of this type one by the patient, in addition to the lemon- was dealing with tabes-like degenera- yellow tint of the skin, would lead the tions in the spinal cord of which the observing practitioner to suspect per- anemia was the primary cause. Since nicious anemia at once. However, as this time exhaustive work has been with other diseases, it is the atypical done both on the cord manifestations picture that offers the greatest diffi- and on the histopathology of the ner- culty in diagnosis. vous system as found in the disease. As the disease progresses towards its Minnich', Burr', Bastianelli\ Putnam", fatal termination it is not at all un- and Taylor'' and Russell', Batten' and common to find various mental upsets, Collier' were among the first writers to and those observers who have had op- direct attention to these early neurolo- portunity to follow a number of cases, gic findings and to emphasize their im- including Addison, who first described I'ortance. the disease, uniformly report such a di- Later Schaumann", Camp ", Lube'" versified trend of psychic alterations as and Pfieffer" enriched our knowledge of to lead us to believe that any form of this group of cases with illuminating mental disorder may occur in the course descriptions of the symptoms and re- of the disease. port of cases. More recently Wilson'- While the nervous symptoms occur- and Mclver'-, Brandes'% Ballman'-*, and ring in pernicious anemia have been Norbury'-', and others have given us under extensive investigation and the classical descriptions. After an ex- literature on this subject has become haustive study of 150 cases of the dis- rather voluminous, and though it is ease examined at the Mayo Clinic, Wolt- well known that later in the course of man'^ states that approximately 12.7';:< the disease mental symptoms may oc- of the patients came for the express cur, yet there have been only relatively purpose of seeking relief from symp- few cases placed on record in which the toms directly attributable to involve- initial complaint was of cortical origin, ment of the nervous system, and symp- It seems that only within the last few toms referable to the cord were present years has much consideration been given in 80'; of all cases. Barrett'" in 6 cases to the early mental disorders of perni- autopsied showed extensive cord degen- cious anemia, though in all treatises on erative changes typical of pernicious this subject it is stated that mental anemia in 5 and only slight changes in symptoms may occur. And Pfieffer", one. Many other instances could be in describing some of the nervous symp- cited in which evidence of nervous tis- toms of the disease, states that mental sue disintegration occurs, but these are symptoms are rare. Langdon'® has typical. Because these symptoms pre- shown that psychotic manifestations dominate and overshadow the anemia- may develop in persons who are some- picture, these writers and numerous what anemic but in whom the diagnosis others point out the simulation to other of pernicious anemia is not justified, diseases, and call attention to the need and he designates the condition as pre- of thorough and detailed physical, neu- pernicious anemia, rologic, and laboratory examinations. But just as cord symptoms may ap- The more common causes for com- pear long before there is any evidence 668 SOUTHERN MEDICINE AND SURGERY November, 1922. of anemia, so mental symptoms may hemoglobin was 27% ; there were no precede the more common clinical man- nucleated red cells; and the stained ifestations of the disease. Schuele'", smear of blood was not examined. With only 20 years after Addison described this account of the case we are forced the disease, reported 3 mental cases and to agree with Pickett'^ that it might believed that the anemia was of neu- have been a case of paresis instead of rogenic origin. The first case was a pernicious anemia. One year later melancholia agitata, with self-reproach Pickett-^ reports 5 cases with mental and attacks of despairing depression, in symptoms, in one of which the diagnosis a man without hereditary predisposi- had been made before the appearance tion to insanity. Ten years before there of the mental disturbance. In the other had been a syphilitic infection without 4 cases the mental symptoms are not secondary symptoms. The patient had described, and we are not told whether some insight into his condition. Two they were initial symptoms, or whether weeks after the onset of the symptoms they developed in the course of the he developed great restlessness, and had disease. Siemerling- reports a case in to be restrained in his room. Autopsy which there was a history of syphilis revealed chronic atheromatous enceph- ten years prior, and alcoholism six years alitis; chronic leptomeningitis; diffuse prior, to the onset of the symptoms, myelitis. There was thin-flowing blood. No evidence of the luetic infection be- fattening of the heart, and of the pap- ing found at autopsy and the mental illary muscles, the liver and the kidney symptoms being unlike those of al- epithelium. He concludes that there is coholic origin, these factors were not no question that this was a constitu- considered as causative agents. This tional disease with special injury to the patient became fretful and sad; had blood. The second case exhibited symp- outbursts of ill temper ; refused to take toms of deep brain trouble, manifested his medicine; expressed the delusion by loss of memory and by all the minor that his wife would not forgive him be- traits of a weakness of mind, with ir- cause she did not understand him; and ritation — symptoms of mild character, that he was being poisoned by the doc- There was soon established an increas- tors. In 1912, 3 years later, Camp^ re- ing dullness with occasional childish ported a case with mental symptoms ideas and stupid obstinacy. Three when first seen. There was no ante- months after the first signs of the dis- cedent insanity. This case, like that of ease the patient was sent to an institu- Siemerling, was ushered in with fits of tion in a condition of advancing im- ill-temper, in which he would break the becility, with paralytic ataxia, and a furniture, and frighten his family; poorly nourished body, with sallow pale- later, becoming exalted, grandiose, and ness and withered skin. No signs of a expansive, and developing delusions of local or constitutional disease could be being poisoned. Simultaneous with the made out. The third case, a boy, who psychosis there suddenly developed dif- at the age of puberty was seized with a ficulty in walking, cramps in his legs, paroxysm of melancholia with inclina- indigestion and constipation. As Camp tion to suicide, from which his mother declares, the delusions were unsystema- had previously suffered, presented a tized, disconnected and vague. He con- typical picture of this psychosis. Au- eluded "the mental state most nearly topsy confirmed the diagnosis of perni- resembles Paresis, though there hardly eious anemia in both the later cases, seems to be as much intellectual dis- In 1903 Marcus-" reported a case turbance as is usual in any case of de- of what he termed pernicious ane- mentia, and the anger and suspicions mia exhibiting early mental symptoms are rather foreign to the usual paretic resembling paresis, the mental dis- type of case." In this connection, the turbance clearing up with little im- contributions of Barrett^' are particu- provement in the blood. The red cells larly interesting and convincing. He did not fall below 2,400,000; the reports a number of cases with well- November, 1922. ORIGINAL COMMUNICATIONS 569 defined psychoses who had formerly and remained well for several months made no complaint referable to anemia, when he again complained of intestinal Stupor, somnolence, apathy and irri- disorder and became weak. The patient tability, usually attract the attention of immediately entered a hospital, becom- clinicians in the asthenic phases of the ing delirious, and soon dying of perni- disease, but these reports show that cious anemia. In Cabot's^* treatise on definite mental disturbances may occur pernicious anemia, he refers to three as the initial complaint in prenicious patients who were markedly insane be- anemia. His Patients showed consider- fore the appearance of the anemia, but able variety in symptomatology, though he does not describe the mental symp- as a rule they were depressed, irritable, toms nor does he state whether these and suspicious, and gave expression to occurred among his own cases or among delusions of persecution and reference; those he collected. In another article, there was a tendency to confabulation ; he-' refers to prominent psychic factors and two were rather expansive. It is in three cases, in one of which the symp- these paranoid conditions that he es- toms dated from the time when it was pecially emphasizes, thougih clinically the patient's misfortune to witness the there were cases of dementia parecox, suicide of her son. And, again, none of epilepsy, and of the manic-depressive the mental symptoms are described, psychosis. Comprehension and orienta- Rogers-'' reported two cases showing tion were usually clear and there was no mental disorders before there was any marked deterioration ; memory was indication of anemia. The first case, often disturbed. Clinically the degree however, was previously reported by of cord involvement varied widely and Patek-' as one of secondary anemia, there seemed to be no more correlation The latter course of the disease, how- between the mental and cord disturb- ever, justified the diagnosis of pernici- ances than between the degree of ane- ous anemia. This patient was suffering mia and cord involvement ; and likewise from a distinct melancholia with delu- the mental symptoms, as the cord symp- sions of unworthiness, even when she toms, were not dependent on the degree came under observation for the first of anemia. In the majority of cases time. The second case was suffering studied there was a hereditary pre-dis- from mental confusion and wild demen- position to insanity. Barnes-' reports a tia when first seen. Woltman^" reports case with untainted history, except for a case ushered in with acute hallucina- a "childish" paternal second cousin, tory confusion which cleared up after which a few months prior to the time three weeks, to reappear subsequently he saw it, developed mild mental symp- with an exacerbation of the physical toms that entirely cleared up. There condition. He describes it as a psycho- had been attacks of indigestion requir- sis of the infection-exhaustion type, ing a physician. When first seen, the In 1919 Lurie-^ gave an excellent de- patient had developed a slowly pro- scription of four cases in which visual gressive psychosis, emotional instabil- hallucinations, delusions of persecution, ity, with retention of personality which, paranoid ideas, and other systematized with the patient's age, had lead to a delusions were found. In each case, diagnosis of cerebral arteriosclerosis, with a single exception, there was some Later, a hemiplegia developed, which familial mental unsoundness. He be- apparently confirmed the diagnosis, lieves the psychosis should be classified Still later the diagnosis was changed to with the symptomatic psychoses of a pernicious anemia, when a typical blood toxic-organic nature. The whole delu- picture developed. In 1919 Pfieffer'^ re- sional formation is vague, unsystema- ported a case without any taint of men- tized, and loosely connected. Jones^" tal history. The patient complained of and Raphael-^ report a case of a woman weakness, languor and indigestion, re- with tainted heredity who, when first maining away from work for a few days, examined mentally, showed emotional, after which he returned to his duties instability; slight disturbance of mem- 570 SOUTHERN MEDICINE AND SURGERY November, 1922. ory for recent events; circumstantial, the stricture is analogous to the other and at times, irrevelant streams of factors in the causation, such as bothri- thought; delusions of persecution by ocephalus latus, pregnancy and achylia. her husband and of his infidelity. Later, he^' reported a similar case, again Gradually the mental disturbance be- pointing out that strictures of the in- came more pronounced and included testine usually tend to induce secondary terrifying delusions of bodily torture, simple anemia, while pernicious anemia apprehensiveness and agitation. A occurs in such cases only if there is an diagnosis of arteriosclerotic insanity underlying predisposition. Cederburg^^ was made, but later was changed to believes the disease the result of a pernicious anemia, when a typical blood gastro - intestinal disturbance which* picture developed. either allows undigested proteins to be This brings up the interesting ques- absorbed, and, in their future course, to tion of the causal relationship existing act as protein poisons, or, which allows between the anemia and the nervous the absorption of hemolytic toxins. This system changes. This question is of opinion is aJso shared by Squier.". necessity a debatable one because we Eppinger'* believes it to be due to al- know so little of the cause of the ane- tered lipoid matabolism, or to a condi- mia itself. It has already been pointed tion of hypersplenism. As a result of out that some of the earliest writers, the hpersplenism - doctrine, splenec- notabily, Schuele^^ and Lichtenstern^, tomy is often advocated as a therapeutic considered the disease of neurogenic measure. Iwao^" considers amino acids origin. Later Goebepo advanced the to be the hemolytic agency. Hunter^" theory that the anemia was the cause looks upon chronic sepsis as the causa- of the central nervous system involve- tive agent, while others think of the tnent. After years of discussion, the disease as an infection of unknown orig- majority of writers no longer believe m. A partial list of the numerous theo- pernicious anemia a disease per se, but res advanced as to the cause of the dis- the result of some toxin, the source of ease, even from a brief review of the which has brought about a great diver- literature, is positive evidence of our sity of opinions. In 1860 Flint^'^ called ignorance as to the causative agent, and attention to the changes of the gastric we at once must agree with Minot" that mucous membranes as a possible caus- "the cause of this disease is as much a ative factor in the disease. Grawitz^'^ mystery today as when described by believed the frequency in which atrophy Addison in 1855." Yet as Minot further of the gastric mucous membrane, achy- states, "it is probable that the manifes- lia gastrica, and intestinal stasis were tations of the disease depend on a va- associated with the disease, pointed to ^i^ty of partial causes which are differ- the gastrointestinal tract as the pri- ently associated in different cases, the mary seat of the disease. Kahonoff'^ primary one being unknown. This concluded that there existed a causal might well be a constitutional abnor- relationship between gastrointestinal mality, an inherent weakness, which disturbances and anemia, and suggested permitted a reversion of the hemato- that autointoxication of gastrointestinal Poietic functions to a somewhat embry- origin might be an important pathogenic onic type." Schustraw^- has recently factor. Meulengracht^* in reporting a shown that a definite predisposition is case of pernicious anemia that came to essential in the development of the dis- autopsy, and others from autopsy ease in addition to the presence of some records, concludes that pernicious ane- hemolytic factor. Mustelin^^* has also mia may develop on the basis of benign recently published what he considers strictures of the intestine through a Proof of an essential constitutional pre- reabsorption of hemotoxic substances disposition of dominant or recessive from the segment of bowel above the characters. Though we are in complete stricture, if there is a congenital pre- ignorance as to its source, the majority disposition to anemia. He believes that of writers agree that the disease is due November, 1922. ORIGINAL COMMUNICATIONS 571 to some form of toxin. cases which show clinical manifesta- With such a chaotic condition exist- tions of central nervous system involve- ing as to the origin and nature of the ment, but which on autopsy show no toxin responsible for the disease itself pathology of the central nervous sys- we cannot hope to reach any satisfac- tem, can be accounted for. He reports tory conclusion as to the causal rela- in full four cases with early predominat- tionship existing between the anemia ing mental symptoms in support of his and the nervous system changes. Num- claim that the psychoses are of a toxic- erous investigators have tried to cor- organic nature. In each case, with the relate these facts, but when we attempt exception of the first, there is a hered- to review their work, we are confronted itary predisposition to insanity. Minot" with as much theory as in trying to ar- subscribes to the theory. Christian*' rive at the cause of the disease. It has also believes the condition is a general already been shown that some of the disease, in which among other tissues, earlier writers believed the disease to the blood and the blood-forming organs be of neurogenic origin, but in the light are involved. According to Bonhoeffer^% of our present knowledge of the disease Woltman^'-, and others, the well-defined we cannot accept this theory as tenable, psychoses are probably dependent on an Therefore, we must turn to more recent individual predisposition, the pernicious investigations for a satisfactory expla- anemia being more or less independent nation. No better discussion of this of the mental disorder, but the majority subject can be found on record, perhaps, of writers have concluded that psychoses than that of Lurie-\ After a most that cannot be classified among the searching study of the question, and a definite disease-types are placed in the painstaking review of the literature, he category of exhaustive or toxic psy- advances the hypothesis that offers the choses. From a study of the cases re- most satisfactory explanation. He be- ported above it would seem that those lieves that one toxin causes both the mental disturbances directly dependent blood and central nervous system, thus on pernicious anemia should be placed changes bv acting independently on the in this group. The case which is here blood and central nervous svstem, this reported only from the clinical side cer- accounting for those cases in which the tainly falls among the toxic psychoses, neurological symptoms manifest them- REFERENCES. selves before the anemia; and those in- i. Lichtenstem, 0: Progressive Pemiciose stances in which the anemia precedes Anamie bei Tal)eskranken. Deutsch. Med., the cord and brain changes ; and lastly Wchnschr 1884, 10 849. , . , „ . ,, . L-- L i.v . J. 2.. Lichtheim: Zur Kenntniss der Perm- those cases in which the symptoms of ^j^^^^ Anamie. Verhand. d. Cong. f. inn. both arise simultaneously. At first the Med., 1887, 6, 84. central nervous system symptoms are 3. Minnich, W: Zur Kenntniss der inn. due to the irritating influence of the Verlaug. der Perniciosen Aanimie beobach- i. • 1 , J., ,1 -1 tenten soinal Erkrankungen. Ztsch. i. Kim. toxm, but after the anemia has per- Si8i)3, 21, 25 and 264; also 1893, 22, 60. sisted for sometime then it becomes a 4 ' gyrr, C. W.: The Spinal Cord Lesion highly destructive agent through a state and Symptoms of Pernicious Anemia. Univ. of malnutrition of the nerve cells. In Med. Mag., 1894, 7, 472. , . , this way the central nervous systems J- ,^^^i^^"^'^*;«o« ' "^ ,.v.^, , J Med. di. Roma, 1896. which, at first, were temporary and g Putnam, J. J., and Taylor, E. W.: Dif- functional, become organic and perma- fuse De-eneration of the Spinal Cord, nent, the damage being irreparable, no Journal of Nervous and Mental Diseases, 1901, matter what form of therapeutic 28:74. „ „ ,, j ^ „• t^ • -.aaa J , J T^ u 7. Russell, Batten and Collier: Bram 1900, measures is adopted. If, however, gg treatment is instituted in the early g. Schaumann, 0: Deutsch. Med. Wochen- stages, while the symptoms are func- schr. 1912, 28, 1228. tional, improvement may be expected in 9- Camp, C. D.: Pernicious Anemia caus- proportion to improvement in the phy- Z^^SS^vLST^^^^^ ^X sical state. On this basis, also, those 1912, 8I, 156. 572 SOUTHERN MEDICINE AND SURGERY November, 1922. 10. Lube, F.: Veranderderungen des Zen- 33. Kahonoff: Roussky Vratch. September trals Nervensystems bei Pernicioses Anamie. 7, 1913. Deutsche Ztschr. f. Nervenhk. 1913, 46, 299. 34. Muelengracht, E.: Arch. f. Verduungs- 11. Pfieffeu, J. A.: Neuropathological krh., 1921, 28, 216. Findings in Case of Pernicious Anemia with 35. Muelengracht, E.: Acta. Med. Scandin. Psychic Implication. Jour. Nerv. and Ment. 1922, 56; 432. Dis., 1915, 42, 75. 36. Cederburg, A.: Berl. Klin. Wochen- 12. Wilson, G., and Mclver, J,: On the schr., 1914, 51, 585. Posterolateral Sclerosis in Cases of Severe 37. Squier, T. L.: Jour. Lab. and Clin. Med., Anemia. Penn. Med. Jour., 1921, 25; 189, 1916-17, 2, 552. Dec. 38. Eppinger, H.: Berl. Klin. Wochenschr.. 13. 'Brandes, H. A.: Spinal Cord Manifesta- 1913, 50, 1509. tions of Pernicious Anemia. Minn. Med., 1921. 39. Iwao, T.: Biochim. Zeitschr. 1914, 59, 4:564. 436. 14. Ballman: Early Appearance of Spinal 40. Hunter, W.: Brit. Med. Jour. Nov. 9, Cord Phenomena, Med. Klinik., 1921, 17:249. 1907. 15. Norbury, F. G.: Early Neurologic Find- 41. Minot, G. R.: Oxford Loose Leaf Medi- mgs m Pernicious Anemia. Illinois Med cinue 3 589 Jour., 1921, 40:273. '.o o v 4. xt -74. i. ^ t^t ht j i« -nr^iL^o,, XT WT TV, XT o 42. Schustraw, N.: Ztschr. f. Kim. Med.. 16. Woltman, H. W.: The Nervous Symp- .qg. ^o 501 toms in Pernicious Anemia. Am. Jour. Med > > • Sc. 1919. 157 400. 43. Mustelin. 0.: Acta. Med. Scandin. 1922, 17. Barrett,* A. M.: Mental Disorders and ^^' ^H- Cerebral Lesions Associated with Pernicious 44. Christian, Henry A.: Intemat. Clin. Anemia. Am. Jour. Insan., 1913, 69, 1063. 1922, 1:8. 18. Langdon, F. W.: Nervous and Mental 45. Bonhoeffer, K.: Ueber Psychische Ston- Manifestations of Prepernicious Anemia. Jour ingen bei Anamischen Processen Berl. Klin. Am. Med. Assn., 1905, 45, 1835. Wchnschr. 1911, 48, 2357. 19. Schuele, H.: Beitray Zur Kenntniss der ^q Woltman, H. W.: Brain Changes Asso- Perniciosen Aanamie. Allg. Ztschr. f. Psy- ^j^ted with Pernicious Anemia. Arch. Int. on ' If ' 'i r. u V ,, • • Med. 1918. 21, 791. 20. Marcus, H.: Psychose bei Pernicioses Anamie. Neurol. Centralbl., 1903, 22, 453. 21. Pickett, W.: Mental Symptoms Asso- ciated with Pernicious Anemia. Am. Jour 4;ttppi7.tjv f\V TTTP THVWnin AG Med. Sciences, 1904, 127, 1032. feUKlxl^Kl \Jt IHti ItllKUlLI Afe Jir, !:7?:x^^\it:::^r]^. influenced by our newer Arch, of Psychmt, 1909 45 567 KNOWLEDGE.* 23. Barnes, F. M.: The Neurological Mani- festations of Pernicious Anemia. Jour. Mis- souri State Med. Assn., 1914, 10, 452. Le Grand Guerry, M. D., 24. Cabot, R. C: Osier's and McCrae's „ , , . „ n Mod. Med., 1915, 4; 819. Columbia, S. C. 25. Cabot, R. C: Pernicious Anemia; A study of 110 Cases Am. Jour. Med. Sc, 1900 The study of the thyroid gland IS a 120; 139. theme of extreme fascination and in- 26. Rogers, A. W.: Disturbances of the terest. It was Osler, I believe, who Central Nervous System Accompanying Per- ^^-^ ^^^^ ^^^ ^^^j^ ^^^^ ^ j^^ ^^^_ nicious Anemia. Jour. Nerv. and Ment. Dis,. ,. ,. , ■, -, 1 ^ 1915, 42; 693. plications and sequelae, and be a good 27. Patek, A. J.: Family Pernicious Ane- doctor. I am wondering if the same chiat., 1919, 2; 67. statement may not be equally true 28 Lurie, L. A.: Pernicious Anemia with ^^^^ applied to the thyroid gland. Cei- Mental Symptoms. Arch. Neurol, and Psy- ..1,1 • . •• chiat 2- 67 1919 tamly there is not an organ or tissue 29." Jones', B. L. and Raphael, T.: Differ- ^^ the body immune from the effects of ential Diagnostic Difficulties in Pernicious thyroxin; and activating principal. Anemia with Associated mental Disorder For the purpose of keeping COnseCU- Arch. Neurol. & Psychiat., 1920, 4, 55. tively before your minds the whole pic- 30. Goebel, w.: Ruckenmarksveranderun- ^^^e I remind you that embryologically, gen bei Pernicoses Anemie. Mitt. a. d. Hamb. .-.^ 4-i,Tr-^^i^ n,i^^A /lr.TT«l^T^o -P>.-^-,^ fVio Staatsgrangennanst., 1898, 2, 1. ^^^ thyroid gland develops fiom the 31. Flint, A.: Med. Times, September 15 Pharyngeal hypoblast, being the median ^^^^' ^ T. , X, ,., , xr,. • , *Read before the meeting of the North 32. Grawitz, E.: Methodik der Klmischen Carolina Medical Society, Winston-Salem, N. Blutuntersuchunger. Leipzig, Thieme, 1906. C., April 26, 1922. November, 1922. ORIGINAL COMMUNICATIONS 573 and lateral inversions. It is an extreme- physiological chemists, ly vascular ductless gland, situated at Jaffory described the areas of pigmen- the front and side of the neck and only tation around the eyes and other parts a short distance above the sternum. The of the body, and Dalrymple described gland consists of two lobes, a right and the contraction of the upper eyelid. ]eft lobe respectively, connected by an I have brought to your notice a num- isthmus ; the lobe being on each side of ber of these clinical descriptions, which the larynx and very closely associated represents one great phase of clinical with it : the isthmus connecting right medicine, in order to bring into sharper and left lobe, hence its name. contrast, and at the same time greater The gland usually weighs about one harmony, the fuller understanding that ounce; is extremely vascular, and it is has been gained through recent chem- not only interesting but important to ical studies of thyroid function, know, that it has about 1-6 as much The older doctors were wonderful blood as goes to the entire brain and clinicians, students, and observers, this from the same source. Evidently They greatly excelled us in this phase nature entertains the highest regard for of work. We need today to take a back- this ductless gland or she would not so ward step, so to speak, and cultivate our protect it. powers of observation vastly more than The older clinicians before the era we do. of modern chemistry, gave wonderful There should be and there is a mid descriptions of the clinical manifesta- ground between the laboratory and the tions of hyperthyroidism. Accordingly clinician. we find as early as 1786 that Parry de- what then is hvperthyroidism, so far scribed this disease very clearly; nearly as our newer knowledge is concerned? one and one quarter centuries ago this in the Journal of Biological Chem- was. istry for August, 1919, Kendall an- In 1800 Flajani, an Italian physician, nounces that he had isolated and iden- also wrote a clear description of this tified thyroxin, which is the hormone or malady. The picture he gave was not active principal of the thyroid gland, as vivid as that of Parry but evidently This active principal has been described it must have been the .^ame disease that as a "catalyst that accelerates the rate he was talking about. In 1835 Graves of formation of the quantum of poten- gave his classical description and pub- tjal energy in the cells of the organism, lished it in book form eight years later. The disease then that we speak of as This description of Graves was so won- hyperthvroidism, is the clinical syn- derfully accurate that the English ^jrome caused by an excess of thyroxin speaking people gave to the disease his being present in the body. We know "^"^e. definitely that this active principal or In 1840 Von Basdow also described hormone, will increase greatly the meta- the symptom complex. This article of bolic rate at which we live." Basdow's was followed by innumerable Kendall has this to say in the article descriptions^ Cnarcot m 1856; Von ^^^f^,,^,^^ t^. 'The clinician is able, by Graff^e in 1864; Stellwag in 1865. ^^ analysis extending over thousands of You will recognize at once that many ^^^^^ ^^^^ ^^^^ ye^rs observation, to of the signs, Von GaflFe s signs for in- establish certain fundamental aspects stance, bear the name of the one who ^^ ^^^y^.^j^i activity which find their discovered the sign. p^,^^^ -^ definite clinical syndromes. In 1886, however, Moebus experimen- The pathologist can relate conditions of tally proved that Grave's disease was the gland showing various stages of ac- due to an overdose of the thyroid gland tivity and inactivity to certain clinical secretion gaining access to the circula- manifestations. The physiologist is tion. able to assign, within broad limits, the The work of Moebus really antici- function of the thyroid, but no ultimate pated the investigations of more recent proof or quanitative conception could be 574 SOUTHERN MEDICINE AND SURGERY November, 1922. evolved until the thyroid hormone was Pathologically speaking, the distin- separated as a chemical entity and its guishing thing in the cases of pure chemical entity and its chemical identi- hperthyroidism, is that we find a great fication mac'e certain. With the struc- hyper-activity in the essential alveolar tural formula of the hormone establish- structure of the gland itself, ed, its mode of action may be directly The true gland cells are driven at a attacked end the final proof of the func- high rate of speed which causes the tion of the thyroid becomes a possibility, manufacture of thyroxin greatly in ex- The circle may be completed and thyroid cess of the needs of the body. It is this activity measured, not by the clinical excessive amount of the hormone acting results of its action alone, but also by on the individual cells throughout the definite chemical substances which will body, increasing the rate of speed at be shown to be the end products of its which we live, that we mean when we activity." speak of the basal metabolic rate being There is one specific and unique phy- increased. In the colloid and adenoma- siologic action of thyroxin which is not *°"« ^o^^^^«' ^^ "^^^ ^^^^ .^""^^^ °^ ^ associated with any other single sub- ^^^"^ ^^^^ ^^^ ^^"^^ overactive but we stance within or without animal organ- ^^^^ ^" addition, an excess of colloid ism. This essential fact has been estab- "material in the one instance and ade- lished. Without changing any other fac- "oj^atous growth in the other tor, the rate of basal metabolism is de- J^ '^ clear from what has been said termined by the amount of thyroxin ad- that many of the thyroid functions are ministered. carried on through the agency of cer- „, ' . . .. , . J - , , tain active principals secreted by it. We are gaming light and knowledge Kendall's work mentioned above, leaves as he chemist pushes his investigation ^^ ^^^^ ^^^ ^^^^^ ^^^^ .^^.^^ .^ ^^^_ of the thyroid gland The common er- ^^j^j ^^^ ^^ ^^^ materials used in the ror of including all disturbances of the ^manufacture of the only active princi- thyroid under the general expression, j ^^^^ ^^ know anything about, goitre, IS fast becoming untenable. ^^^^jy^ thyroxin. In this respect it is becoming impor- Thyroxin is, in all probability, stored tant to differentiate pure hyperthyroid- jn the colloid material found in the ism from adenomatous goitre, since they gjand acini. As it is needed for the are often looked on as essentially iden- body it is absorbed by the passing tical in character. Plummer has point- blood. ed out that a definite symptom of hy- in hyperthyroidism the normal bal- perthyroidism is, with rare exceptions, ance has been disturbed, the gland man- associated with diffuse hypertrophic or ufacturing thereby and blood absorbing adenomatous goitre, just as it follows more of the active principal than nor- the therapeutic administration of thy- mal.. roxin. Whereas hypertrophic goitre is j;;^^ ^^y at times, there should be an the anatomic expression of functional increasing demand for thyroxin we do disturbance m the developed thyroid, an ^ot know. It is probable that the de- adenoma of the gland represents new ^and for the active principal of the tissue developing postnatally from the gjand may be due to certain waste stimulation of embryonic cells. In products flooding the system. For ex- either case, and the two types of goitre ample, from various foci of infection or may be present m the same structure, f^^^ direct ingestion of polluted water, the effects noted are essentially those y-. xi. ^r. u j ^-u i i v • ^• ^- 4.^-, , ,„i,i . 4! 4.U 1 On the other hand the lack of iodine attributable to an excess of the normal ^ ^i. ^ j. ^ ^u ^, . , ^ ^ necessary for the manufacture of the thyroid hormone. Recognition of this, active principal may be responsible in in which the heightened basal meta- some cases. holism assists, points the way to ration- When iodine is lacking the gland al treatment, by removal of the ade- seeks to overcome this deficiency by a noma. compensatory enlargement. November, 1922. ORIGINAL COMMUNICATIONS 575 It is likely then that in the beginning understanding. These cases are of the many hyperthyroids are in reality hypo- same essential nature as the well estab- thyroids becoming hyperthyroids when lished Graves' disease, but they are the gland overcompensates in response wide apart in the point of severity of to the very urgent, insistent, and con- symptoms and differ so greatly as re- stant demands made upon it by the sys- gards mortality prognosis, and treat- tem for iodine and its activating hor- ment, as to necessitate their consider- mone, thyroxin. This cannot be true, ation under a separate head, however, in all cases for there is good The point that I wish to stress about evidence to show that there are cases of the thyroid cases, with all of the em- primary hyperthyroidism which are not phasis and conviction at my command, explained by the above stated ideas as is this: the medical measures in the to causation. early cases should be given a fair and We know it to be true as a matter of reasonable trial. We direct especial clinical experience in the enlarged thy- attention to the expression, reasonable roids of adolescence, with true symp- trial, by which we mean a trial within toms of Graves, that feeding such cases reason ; such a trial as would satisfy iodine will very frequently cause imme- a reasonable man. diate recession of symptoms ; the ex- If the case does not respond promptly, planation being that the gland hyper- a surgical consultation is the irreducible trophies in order to meet the unusual minimum in behalf of the patient. It is demand for iodine at this period of life, not in the interest of the patient's wel- Supplying sufficient iodine by mouth, fare to persist in measures which are the thyroid promptly returns to normal barren of results on the positive side size and symptoms abate. and equally certain on the other hand This brings us then to the question to lead to grave complications and se- of treatment which we will discuss very quelae which mean failure in the end, briefly under two heads: it seems to me no matter what is done. The policy of that what has already been said fur- doing nothing and expecting something nishes a rational basis for treatment. to happen, has very little place here. In the first place then we believe that When the grave secondary changes medical management of these cases has, occur and they surely will as a result of especially in the very early stages, a the toxemia, the blame rests on the definite place: one who is responsible for the delay. A Rest in bed. degenerated and dilated heart muscle; Absolute quiet. an undermined nervous system; second- Freedom from worry. aiy nephritis, etc.; is a direct criticism Careful diet and hygiene. of medical management and brings re- Removal of all foci of infection. proach to surgery. These mild cases have been the occa- We are in the midst now of the claims sion of great confusion, because in esti- of the roentgenologists — just what to mating the results of surgical treatment say about it as a curative agent in any they have been included in the statis- real sense. I do not know. Frankly, tics, when as a matter of fact they my experience leads me to be skeptical, should not be so included. These abor- All of us know of the extravagant tive types of Graves' disease, formes claims made for deep roentgen-ray ther- frustes. with very mild symptoms are apy in deep seated cancer. Certainly really not surgical cases at all. This is the rays and radium produce a dramatic the group for which a great deal can temporary effect, but within the limits be done by judicious and scientifically of my experience, at least, it has been planned medical treatment, in a word, only temporary. I know of eight cases they constitute the medical types of of recurrent cancer; 4 in cancer of the goitre. breast; two in cancer of the jaw; one We use the expression, medical types in cancer of the liver; one in cancer of of goitre, with much trepidation be- the neck; that have died within the cause it is such a fruitful source of mis- last year and every one had had every- 576 SOUTHERN MEDICINE AND SURGERY November, 1922. thing that X-Rays and radium could to act medically, but it is necessary for offer. him to think medically. We have not as yet, so far as I know, been able to regulate the dosage. We are hopeful of the X-Rays, but our posi- tion at present is one of watchful wait- rpjjj, AVOIDANCE OF SHOCK IN ^"^ , , ^ ^ _, .^ THE TREATMENT OF DIFFUSE For Jic sake of argument, we admit pt^tjithmtttq that it is helpful in the medical man- i t.KiiUJMiib. agement of the early cases. A. Murat Willis, M. D., A word in conclusion about surgery : Professor of Surgery, History repeats itself; so likewise does Medical College of Virginia, medical and surgical history. Richmond, Virginia. In the early stages of thyroid surgery practically all of the cases were coming By the employment of a spscial tech- late to operation. Late operation made nic, Murphy, (1) in 1908, reported that a high mortality and high mortality he was able to reduce the mortality made a late operation ; a surgical vicious from diffuse peritonitis to the remark- circle. This state of affairs has been ably low figure of about 4 per cent, completely changed. Since, in many cases of appendicitis, Surgery, in conjunction with the ad- death is in reality due to the develop- vice and council of a real internist, of- ment of a diffuse peritonitis, it would fers a primary mortality of between 5 seem that the adoption of Murphy's per cent and 2 per cent; 85 per cent method in treating this complication conplete symptomatic cures; about 7 would rob acute appendicitis of many per cent receive great benefit ; and a of its terrors and eliminate much of the very small number apparently are not mortality. Evidence presented in such helped. a convincing manner by so distinguish- To recapitulate, we advocate a reas- ed a surgeon soon led to a wide-spread onable medical ma.nagement ; we recog- employment of his method of treatment nize the value and uses of radium and of diffuse peritonitis, and it is now only X-Rays in their place ; but we insist that the occasional voice that is raised a surgical method that offers a mor- against his dictum of "get in quick— tality of 5 per cent, that will practically get out quicker" and his condemnation cure 90 per cent, is a method that can- of the use of saline irrigation of the not be lightly set aside. By the plainest peritoneal cavity. rules of evidence, the roentgenologists Unfortunately, however, others have must establish their claim by showing been unable to snatch from the brink a lower mortality rate and establishing of the grave as large a proportion of a greater percentage of symptomatic peritonitis patients as Murphy reported cures. This is the acid test. he had saved. Not only this is the case. The great problem is to preserve a but it appears that patients still die proper balance between what medicine even from appendicitis. In an examina- can do on the one hand and what sur- tion - of the mortality statistics of the gery can do on the other. registration area of the United States, This is a disease essentially for team comprising about 75 per cent of the pop- work and nothing is so helpful to the ulation, 9,929 deaths were reported as surgeon as the constant council and ad- due to appendicitis during 1918 ; while vice of an able clinician. peritonitis was the contributory cause That master surgeon Kocher, has i" 4,361 of these, said, it was not necessary for the medi- Dr. Stuart McGuire', in a recent cal man to act surgically, but it was paper, quoting Murphy, places the mor- necessary for him to think surgically, tality of all appendicitis, acute and To this we have been pleased to add, chronic, at the astounding figure of thut it is not necessary for the surgeon ten per cent. November, 1922. ORIGINAL COMMUNICATIONS 577 That skilled and experienced sur- rigation predisposes to the develop- geons obtain such results by the em- ment of "shock." This contention re- payment of the Murphy method has em- ceives some support from the experi- boldened me again to question the mental observation that a progressive soundness of certain of the principles lowering of the blood-pressure may be upon which it is based. Dr. Murphy obtained in animals by evisceration and especially condemned the employment manipulation of the intestines ; but in of saline irrigation, both because it properly performed irrigation and suc- tended to disseminate the infection and tion the conditions are absolutely un- also because it removed the "protective like those which obtain in these experi- exudate." Thus, he says: "Washing mental conditions. There is no evis- removes the pus with its myriads of ceration; the intestines are bathed In leucocytes, sent there for the sole pur- wai^m isotonic salt solution, and the pose of protection." In a recent I'ubli- manipulation is of the gentlest nature, cation by Hertzler, 'a similar expression Instead of tending to produce shock, is made in the following words : "Much the employment of irrigation is an ef- harm is done by removing the natural ficacious means for preventing it, as defensive forces of the tissues. The ex- will be shown in the following discus- udate covering the surface of the peri- sion. toneum is composed of serum and cells. Secondary traumatic shock is the and in just the measure that irrigation condition which develops some little is effective, it is harmful by removing time after the reception of cetrain in- this protective measure." juries. As is well known, it is accom- Elsewhere, the attempt has been Ponied by characteristic symptoms; a made-' to answer the arguments that ^^^^''^ o^' S^'^yish or cyanotic skm, cov- have been advanced against the emplov- ei'ed with sweat; rapid, thready pulse; ment of saline irrigation in the presence subnormal temperature; apathy; and a of a diffuse peritonitis. It was pointed Progressive descent of the blood-pres- out there that saline irrigation in such ^^"'e. It has been shown that there is cases could scarcelv be blamed for the an increase in the blood nitrogen and wide-spread dissemhiation of the infec- ^ decrease in the volume while tion, when there was, prior to operation, ^'^ther late, there is an absolute reduc- a free fluid in the cavity which has ac- tion in the alkali reserve of the blood, cess to those regions bathed in the though there is probably a relative in- salt solution when irrigation was prac- urease Recent mvest^ations end to ticed . Both by animal experimenta- ^how hat the earlier theories advanced tion and by clinical trial, it was proved to explain this condition are madequate ; that the use of saline irrigation with ^"f. the evidence that is now available suction, instead of sealing the patient's ^"^icates strongly that traumatic J ,.,.,, n ■, shock m many, if not all cases, is due doom, distinctly favored recoverv. *''^\^ in^nj, ^.^ ■, 4. Evidence was cited, proving conclusive- to the entrance into the blood stream ly that the exudat^ favored the multi- ^^. toxic substances arising from the plication or the bacteria, the dead leu- ^"J"^'^^ tissues. Thus, Cannon and his co-workers' have shown that crushing cocytes and the nitrogenous material of the fluid portion serving as a culture the thigh muscles of a cat will cause ux tiic iium puiLiuu ^civiiifc ao ci ^uiuuic development of a condition which is medium. Though these are weighty . ,. ' . • r, ui -p „u ^^. oo c««r, reasons favoring the removal of the indistinguishable from shock as seen exudate, still another must be recog- ^^i"^^^"/' ^^^ *^!f, ^^" "^'''nTwi nized as rendering it even more imper- f ^^'^'^t nerve pathways ^^e destroyed .. i.u i. ^L. u ^- r i-L- ii -J bv section of the lumbar cord. On the ative that the absorption of the fluid ^[ . ^^^ ^^^^^^^ ^^ ^^, should be prevented. oj ^^^^^^ ^^/^^^^ .^ ^^^ blood-pres- The advocates of the Murphy method ^^^^ . ^^^ich occurs promptly on re- stress the importance of speed in oper- ^^^^^j ^f ^^e clamp. French surgeons, ating. The added time and the intesti- f^om clinical observations, were early nal manipulation demanded in using ir- impressed with the fact that there ap- 578 SOUTHERN MEDICINE AND SURGERY November, 1922. peared to be a toxic factor in traumatic shock, and they have accumulated many observations in support of this view. The investigations of Dale, Barger, Laidlaw, and others serves to explain the mechanism that is probably involved and also to identify one probable agent concerned in the production of shock. They have shown that histamin, a cleavage product of protein, when in- jected intravenously in small doses causes a marked fall in the blood-pres- sure, and this depressor action occurred in spite of arterial constriction and an absence of cardiac weakening. Further study showed that the fall in pressure was due to capillary dilation, accom- panied by an increase in the permea- bility of the capillary walls, the latter leading to a loss of fluid from the ves- sels and a consequent increase in blood concentration identical with that seen in traumatic shock. It is believed that histamin is only one of a number of substances which arise in the process of protein hydrolysis; a hydrolysis which may occur in dead tissue free from bac- terial contamination but which is markedly accelerated by the presence of proteolytic organisms. To summarize, it may be asserted without fear of contradiction that cer- tainly many cases of traumatic shock are due to the entrance into the circu- lation of toxic materials which arise as a result of protein cleavage. Among these cleavage products, histamin has been identified and its affects after in- travenous injection are similar to or identical with those which occur in ani- mals whose thigh muscles have been crushed and lacerated and in men who have sustained wounds involving ex- tensive destruction of muscular masses. From a practical standpoint, it has been shown clinically and experimentally that striking benefit may be obtained by the prevention of the entrance of these toxic agents into the circulation, either by removal of the dead tissue or by clamping the vessels leading from the traumatized area. If we accept the view that autolytic decomposition of the protein of dead muscle can occur to such an extent that the cleavage products enter the circu- lation and produce shock, does it not seem that even more pronounced effects will follow from the decomposition of a nitrogenous fluid teeming with proteo- lytic bacteria in a cavity with such powers of absorption as are possessed by the peritoneum? In view of this evidence, which pro- cedure would seem more likely to pro- duce "shock;" a hasty, incomplete oper- ation, leaving the abdominal cavity filled with a mass of decomposing exu- date ; or one which removes the major part and dilutes the remainder? In carrying out the technic associated with "irrigation," adhesions are gently broken up ; all pus pockets are emptied ; and the peritoneal cavity flooded with warm saline. Simultaneously, by means of an electric suction apparatus, the di- luted exudate is removed as completely as possible. If striking effects have been obtained in the alleviation of shock through the amputation of a trauma- tized limb, or the removal of dead mus- cular masses, would it not seem logical to attempt a similar "debridement" in the treatment of diffuse peritonitis? The use of drainage is simply a salve to the operator's conscience ; the drain soon becomes walled off and completely sep- arated from the general cavity; it is only by irrigation that the exudate can be removed. In accomplishing this, we remove a supply of nourishment from the bacteria and in this way increase the patient's chances of recovery. We must now recognize an additional benefit to be derived from the procedure; by ir- rigation and suction we are checking the entrance into the circulation of poisonous products of protein decompo- sition and are relieving or preventing the development of the depressed con- dition designated as "shock." BIBLIOGRAPHY. 1. Murphy, Tr. Am. Surg. Assoc, 1908, XXVI, p. 46. 2. Willis, Surg. Gynec. & Obst., Oct., 1921, p. 355. 3. McGuire, Southern IVIedicine & Surgery, March, 1922, p. 124. 4. Hertzler, "The Peritoneum," St. Louis, 1909. 5. Cannon, Arch, of Surg., Jan., 1922, IV, p. 1. November, 1922. ORIGINAL COMMUNICATIONS 579 suggestive of tuberculosis of the uterus. TUBERCULOSIS OF THE UTERUS. J.^^ carcirai^UrS°etdomelitt syphilis and and tuberculosis. Report of a case by Tj^^ diagnosis of tuberculosis can be Brodie C. Nalle, M. A., M. D., F. A. C. S., made, according to Cummings, in an ar- Charlotte, N. C. ^^^^^ published in 1912, by the detection of bacilli in smears obtained from the I hope the scarcity of reports of cases cervix, and by microscopic examination of Tuberculosis of the Uterus, and the of the tissues removed by the curette. desire to add the report of a case to the The prognosis depends upon the stage very small number of reported cases, at which the disease is detected and justifies me in presenting this paper. whether its presence in the uterus is The Index Catalogue of the Surgeon primary or secondary. Generals' Library and the Index Medi- The treatment is (1) surgical, (2) cus through 1919 show reports of only X-Ray, or the combination of both. The 146 cases of Tuberculosis of the Uterus, constitutional treatment must always excluding those cases invading only the be borne in mind, and especially when cervic uteri. The Bibliography for the the uterine tuberculosis is secondary to past ten years includes a comparatively some other active focus. Surgical treat- small number of contributions. The ment alone is permissible where the dis- greater part of these contributions have ease is primary and confined to the end- come from foreign authors. Only a ometrium. Scott, in an article in the very small number have come from the California Medical Journal, in 1919, says United States. that simple curettement will cure pri- It is the concensus of opinion that mary tubercular endometritis where Tuberculosis of the Uterus is by no the disease has not reached the tubes, means a curiosity, but the scarcity of Complete hysterectomy is indicated reports of cases of the disease is at least when the disease has reached as far as surprising and suggestive of the fact the appendages. that a large number of these cases pass Deep X-Ray treatment alone is ad- unreported and possibly unrecognized, visable in those cases in which, for any Tuberculosis of the Uterus occurs in reason, operative treatment is contra- four varieties — Ulcerative, Miliary, In- indicated, terstitial and Peritoneal. While a good many authorities con- "In the miliary type of the disease sider sugery alone sufficient, it seems the mucosa is studded with minute more logical and much safer to follow slightly raised yellowish-white tubercles, all operated cases with deep X-Ray It is practically agreed that as soon as treatments. ulcers develop in the mucosa the disease E. Vogt, of Berlin, says he "has ex- has passed from the miliary to the ul- amined the curative effect of post-oper- cerative type." (Scott.) ative roentgenotherapy in 33 cases of The interstitial variety is less fre- tuberculosis of the female genitalia. In quent in its occurrence than either of 25 cases of genital and peritoneal tuber- the other varieties. culosis the ascites was drained through The peritoneal variety is secondary to a simple exploratory laparotomy open- a tuberculai' peritonitis. ing; in four of the cases a conservative The symptoms are those of other in- adnexopexy and in four cases a radical flamatory uterine conditions :—dysmen- operation was performed prior to the orrhea, metrorrhagia and menorrhea. roentgenotherapy. As soon as the pa- The sensation of weight and pain in the tients were able to leave their beds the pelvis, progressive constipation, painful roentgenotherapy was begun, and lasted defecation and pain radiating from the for several months ; there was an inter- hypogastrium to the lumbar region, to val of from four to six weeks between the thorax and along the perineum are the sixth and the tenth irradiation. Of 580 SOUTHERN MEDICINE AND SURGERY November, 1922. the 33 patients nine died before the ter- ative treatment is contra-indicated. It mination of the treatment. The cura- is just in cases of this sort that the tive effect of the treatment could thus value of radiotherapy becomes strjking- be observed in the case of the 24 pa- ly apaprent. Among such contra-indi- tients who were examined after the cations the author cites ascites with termination of the treatment. Of them fever, active lung processes or active 21 are now able to work, 2 are only part- tubercular foci in other organs." ly cured and one is an invalid. The ^^g^, report records of various gynecologists show that the average percentage of the pa- ^^^^t;^;' ^^fj^j TJ'J!!',..!!!'"!"!'" : tients suffering from genital and peri Family history: Negative for tuberculosis. Mensti-uation began at 15 years; painful but toneal tuberculosis who have been per- otherwise normal. Married at 18 years; be- manently cured by operation is about came pregnant one month later, but mis- 33 per cent. In 16 similar cases, in carried at three months. Her second preg- which post-operative roentgenotherapy l^f^^^ ^^"^^« ""T^'^.T"^ *S '^'H '" "T ,. -, \^ n ^i ,• . oA -1 years old and healthy. She afterwards was applied, 13 of the patients— or 80 ^^j ^^.^ ^^ore miscarriages, each about four per cent — were permanently cured. A months. Each of her miscarriages were, ac- fistula was never observed in these cording to the patient, precipitated by a se- cases; although Kronig observed fistulae ^•^^•«' dysentery. Operated for cystocele and _ , J. .I 1-11 permeorrhaphy ten years ago. Married sec- in 8 per cent of the cases which he ^^^ ^ime 8 years ago. No pregnancies since, treated surgically. The roentgen treat- Menstruation has been irregular and occa- ment also affected the menstruation of sionally profuse for past three years. the patients very favorably ; in only 42 On May 5th, 1921, I saw this patient, per cent did a permanent roentgen whose complaint was a metrorrhagia of amenorrhea occur, and 58 of the pa- five weeks' duration. Physical exami- tients began to menstruate regularly a nation was negative, except for her corn- short time after the treatment. Plaint and a secondary anemia. She "These favorable results show that ^'^s curetted on May 7th, 1921; return- the roentgenotherapy favorably affected ed to work at end of one week. Micro- the condition of all the patients who had ^copic examination of the tissue gotten been previously treated surgically. The by the curette was examined by two author, therefore, recommends that different Pathologists at different lab- post-operative roentgenotherapy be ap- oratories and diagnosed by each as tu- plied in all the following cases : (1) after bercular endometritis of the miliary every operative treatment of genital ^^Pe- The patient was advised of the and peritoneal tuberculosis, in which a diagnosis, but refused further treat- part of the affected tissues cannot be "^ent. She enjoyed splendid health for extirpated; (2) after exploratory lap- ^he following ten months and could not orotomy with drainage of the ascites, ^e persuaded that her trouble was at all and after radical operations during venous, especially since not even her which a tuberculous process has been menstruation appeared again after the observed in the peritoneum; (3) in curettement. However, a few weeks cases in which an adnexopexy has been fso she began again with an excessive performed, but in which the thorough- loss of blood, and this has continued ness of the operation has been hindered with some intermissions until this time, by severe adhesions; (4) and also in She has consented now to submit to cases in which menorrhagia or metror- further treatment, which will consist of rhagia occurs after the adnexopexy. either curettement or hysterectomy, fol- "Roentgen therapy in genital tuber- lowed by deep X-Ray therapy. Very culosis is advisable under the following recent physical examination shows no conditions: (1) in cases of endometritis ^. ^^ tuberculosis elsewhere, so I feel tuberculosa, resulting m dismenorrhea . ^.^ , . ^. ^- . , ,, or menorrhagias without evidence of ex- Justified m reporting this as a probable treme involvement of the adnexa or per- case of primary tuberculosis of the itoneum. (2) If, for any reason, oper- endometrium. November, 1922. ORIGINAL COMMUNICATIONS 581 Conclusions. (1) Tuberculosis of the Uterus oc- curs at all ages, but is most common be- tween the ages of 20 to 30 years. (2) It occurs more often than is suspected from the number of cases re- ported. (3) Symptoms are similar to other inflamatory conditions of the uterus. (4) The primary form of the dis- ease is comparatively rare — most cases being secondary, (5) It occurs in four main types — miliary, ulcerative, inter-stitial and peritoneal. (6) Prognosis in early detected cases with the present ideas of treat- ment is not so bad as has been gen- erally supposed. (7) X-Ray treatment for those cases in which surgery is contraindicated, with post-operative X-Ray treatment for those cases in which surgery is not con- traindicated. niHLIOGHAPHY. Two cases of Uiberc-ulosis of the uterus. M. J. Stewart— Glasgow M. J. 77:255-260, 1912 (1 pi.) Difi'use tuberculosis of the uterus. C H. Roberts. Proc. Rog. Soc. Med., London Sect., Obt. Gynec, 57-61, 1911-1912. Tuberculosis of the uterus, with report of one case. P. Romeo. Gazz. d. osp., Milano, 32:101-106, 1911. Clinical study of tuberculosis of the uterus. F. Terrades. Rev. de med. y cirug., Barcel., 25:121-156, 1911. Observalions on uterine tuberculosis. H. Schiffer. (Giessen) 80. Berlin, 1912. Case of tuberculosis of uterus. A. Rispal and A. de Verbizier, Toulouse Med., 14:377-38-3, 1912, 2 s. Diagnosis of tuberculous endometritis by staining bacillus in smears obtained from cervix. H. Cummings, Physician & Sug., De- troit and Ann Harbor, 34:202-206, 1912. Uterine Tuberculosis. Goullioud, Lyon Med., 121:507-509, 1913. Tuberculosis of the uterus. J. W. Thomson Lancet, London, 2:1000, 1913. Diagnosis and treatment of genital tuber- culosis in women. Sellheim, Hegar's Beit- rage, Bd. 6, 1912. Tuberculosis of the advexa and coecuni of the uterus; extirpation of the uterus and of the appendages, and resection of the coecum. J. Szili, Sebeszet, Budapest, 1912, 16. Case of endometritis tuberculosa. E. Mis- cura. Rev. Ospedal, Roma 4:65-75, 1914. Two cases of tuberculosis of the uterus. E. G. Stilman, Proc. New York Path. Soc. 14:101-108, 1914. Contribution to the study of primary tuber- culosis of the uterus. E. Astrie (Lyon) Val- ance, 1914. Ducros & Lombard. 88 p. No. 148, 80. Concerning intra-uterine miliary tubercu- losis. H. Rollett, Wien. klin. Wchnschr. 26:1274, 1913. Tuberculosis of genital organs in women. Meyer-Ruegg. Ref. Zentralbl. 791, 1914. Genital and peritoneal tuberculosis in the Wurzburger Univresitat. Frauen Klinik. Min- ncr. Wurzburg, 1914. Therapy of genital tuberculosis in women. H. Kroner, Arch. f. Gynaek. Bd. 105:169-189, 1916. Tuberculosis of female genital organs. M. Rudeloff, Zentralbl. f. Gynak., 45:854, 1921. Tuberculosis of female genitalia. A Bauer- eisen, Zi-ntralbl. f. Gynak, 44:905, 1920. Pathology of uterine tuberculosis. P. Sch- roder, Monats. f. Geburt. u. Gynak., Berlin 55:15-24, 1921. Tuberculosis of genital organs in women. R. Kundrat, Arch f. Gynak., Bd. 114:51-101, i;»20-l