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Vol.  CX 


MAY,  1916 


Number  5 


NASHVILLE  JOURNAL 


OF" 


MEDICINE  AND  SURGERY 

EstablUhed  1851 

CHARLES  S.  BRIGGS,  A.  M.,  M.  D.,  Editor  and  Proprietor 
E.  S.  McKEE,  IVI.  D.,  Cincinnati,  Associate  Editor 
W.  T.  BRIGGS,  IVI.  D.,  Associate  Editor 


PUBLISHED  MONTHLY     - 


$1.00  a  Year  in  Advance 


EtUfrfd  at  thf  Post-Officf  at  SaskvilU.  Tenn..  as  Second-Class  Afattet 


Williams  Ptg   Co,,  Printers.  166  Fourtli  Avenue.  North,  Nashville.  Tenn. 


Quality 

Efficiency 

Uniformity 

Tongaline 


Rheumatism 

Neuralgia 

Sciatica 

Lumbago 

Tonsillitis 


THE 

Salicylic  Acid 

--  • 

inTongaline 

IS  MADE 
FROM  THE 

Natural 
Oil 


Grippe,Gout 

Nervous  Headache 

Malaria 

Heavy  Colds 

Excess  of  UricAcid 


Z.r.znr'i.E.s  oim  appuic/vtion      xvieli-iefi   dfujo   go ivi f»./»wIm y. ,  s t.  uo u i s 


(Eontputa  for  Mn^,  191 B 


ORIGINAL  COMMUNICATIONS. 

Eclampsia    -^"^"^ 

SELECTED  ARTICLES. 

Influenza    ^^^ 

EXTRACTS  FROM   HOME  AND  FOREIGN  JOURNALS. 

Surgical. 

Operation  for  Aneurysm  of  Extremity 215 

Thread  Drainage 215 

A  Simple  Method  of    Removing  Flat  Foreign    Bodies 

from  the  Trachea  of  Young  Children 216 

Intravenous  Injections  of  Chloral  in  the  Treatment  of 

Tetanus 217 

Medical. 

Chenopodium  in  the  Treatment  of  Unciniariasis 218 

Copper  Sulphate  Treatment  of  Trachoma 218 

Magnesium  Sulphate  in  Non-Am^oebic  Dysentery 219 

Mobilization  of  the  Lung  in  Treatment  of  Pulmonary 
Tuberculosis  in  Early  Stages 219 

Obstetrical. 

Painless  Childbirth   220 

Cesarean  Section 222 

EDITORIAL 223 

REVIEWS  AND  BOOK  NOTICES 226 

PUBLISHER'S  DEPARTMENT   237 


In  the  treatment  of  Summer  Com- 
plaints of  Infants  and  Children 

"The  clinical  basis  of  treatment  is  antisepsis  and  disinfec- 
tion of  the  intestinal  tract ;  not  with  a  purpose  to  completely 
destroy  the  offending  bacteria  and  their  toxines,  which  we 
know  to  be  neither  possible  nor  necessary,  but  to  assist  the 
normal  defenses  of  the  body  to  gain  the  ascendancy." 

"There  are  four  principles  of  therapy  which  govern  the 
treatment  of  these  infections : 

"(a)   To   give   the    gastro-intestinal    tract   physiological 

rest." 

"(b)   To  remove  as  much  as  possible  of  the  infective  ele- 
ments." 
"(c)   To  stimulate  natural  defenses." 

"(d)    To  reinforce  these  natural  defenses  with  local  anti- 
sepsis." 

"By  local  antisepsis  we  can  inhibit  many  of  the  patho- 
genic bacteria  in  the  bowel  before  they  enter  the  mucosa. 
The  antiseptic  agent  must  be  selected  with  a  view  to  certain 
requirements :  for  example,  it  must  not  be  strongly  acid.  It 
must  not  coagulate  mucin.  It  must  not  be  astringent.  It 
must  be  easily  soluble  and  not  upset  osmotic  conditions,  and 
finally  it  must  be  non-irritant  and  non-toxic." 

"Listerine  answers  to  all  these  requirements  and  furnishes 
an  ideal  agent  of  local  antisepsis  in  these  cases.  It  has  the 
additional  advantage  of  being  compatible  with  almost  any 
other  medicinal  agent  with  which  the  physicians  may  desire 
to  administer  it." 

The  above  is  abstracted  from  a  pamphlet  entitled 

"Acute  Intestinal  Infections  of  Children" 

a  copy  of  which  we  shall  be  pleased  to  send  to  physicians 
upon  request. 

Lambert  Pharmacal  Company, 2101  Locust  St., St.  Louis,  Mo., U.S. A. 


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The  Jefferson  Medical  College 

182^  OF  PHILADELPHIA  1909 

A  Chartered  University  Since  1836 

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Clinical  results  have  proven  to  thousands  of  physicians  that  Anasarcin  is  of  un- 
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and  of  ascitic  conditions. 
It  controls  heart  action,  relieves  dyspnoea  and  eliminates  effused  serum. 

Anasarcin's  Distinctive  Features 

Dependability  of  the  cardiac  stimulant  and  diuretic  properties  of  its  ingredients 
made  certain  by  standardization. 
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NASHVILLE  JOURNAL 

MEDICINE  AND    SURGERY 


CHARLES  S.  BRIGGS,  A.M.,  M.D.,  Editor. 
W.  T.  BRIGGS,  B.A.,  M.D.,  Associate  Editor. 


Vol..  ex.  MAY,  1916.  No.  5 


QPrtgtnal  (KnmmuntraltnnB 


ECLAMPSIA.* 


BY  SAM  K.  COWAN,  M.D., 

Nashville,  Tenn. 


Eclampsia  is  a  symptom  complex,  presented  by  pregnant 
women,  of  which  convulsions,  followed  by  coma,  are  the 
most  prominent  manifestations. 

Its  history  dates  back  to  the  time  of  Hippocrates,  who 
mentions  convulsions  occurring  in  those  pregnant  women 
who  had  headache,  and  were  inclined  to  sleep. 

It  occurs  in  from  2  to  4  per  cent  of  pregnancies  and  us- 
ually during  the  later  months  of  gestation,  although  fatal 
cases  are  known  in  the  4-6  mo.,  and  it  has  been  reported  as 
early  as  10th  week. 

In  about  20  per  cent  of  cases  convulsions  appear  during 
pregnancy,  60  per  cent  during  labor,  and  20  per  cent  during 
puerperium. 

Cause — All  authorities  agree  that  it  is  a  toxemia,  about 
the  origin  of  which  many  theories  have  been  advanced,  but 
none  have  been  proven.    The  liver  is  accused  by  some,  the 

*Read  before  Nashville  Medical  Symposium,  March  22,  1916. 


194       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

kidney  by  others,  on  account  of  the  pathology  of  these  or- 
gans found  on  autopsy.  Franke  claims  ferments  in  the  pla- 
centa may  produce  the  toxins. 

Disturbed  glandular  balance  between  the  organs  with  in- 
ternal secretions  is  another  theory.  Lange  has  cured  the 
albumin  of  pregnancy  by  the  administration  of  iodothyrin, 
and  believes  the  thyroid  gland  responsible.  Others  have 
used  thyroid  extract  successfully  in  albuminuria,  also  acid 
intoxication  has  its  followers.  Quite  a  few  men  claim  it  is 
an  infection  on  account  of  its  febrile  nature,  occurring  in 
previously  healthy  women  after  a  few  days  prodromata, 
and  on  account  of  the  fact  that  it  frequently  follows  tonsil- 
litis or  some  other  acute  infection;  also  on  account  of  the 
frequency  of  sepsis  in  eclamptics. 

It  is  thought  to  be  allied  to  uremia,  and  while  albumin  is 
found  in  the  urine  of  all  eclamptics  it  has  not  been  decided 
whether  the  kidney  lesions  are  the  cause  or  result  of  the 
cause. 

Cause  of  convulsions — The  toxins,  if  they  are  the  cause 
irritate  the  nerve  centers  as  do  other  specific  poisons — 
strychnine,  tetanus,  etc.,  with  a  special  affinity  for  the 
cortex  of  the  fore  part  of  the  brain,  and  as  in  other  poisons, 
are  induced  by  external  irritants,  as  slamming  doors,  jar- 
ring bed,  external  or  internal  examination,  induction  of  la- 
bor, hypos,  enemas,  etc. 

Predisposing  causes  are  previous  attacks,  primiparity, 
especially  in  advanced  years,  heredity,  excessive  nervous  ir- 
ritability, multiple  pregnancies,  contracted  pelvis,  infantal- 
ism  and  previous  diseases  of  liver  and  kidney. 

Pathology  is  found  on  autopsy  in  brain,  liver,  kidneys, 
circulatory  system,  lungs,  and  changes  corresponding  to 
those  in  mother  are  found  in  fetus.  In  the  brain  there  is 
flattening  and  moderate  edema  of  convolutions  with  anemia 
or  congestion.  Hemorrhages  or  areas  of  central  softening 
with  thrombosis. 

The  liver  shows  the  most  typical  and  constant  changes. 
There  is  albuminoid  degeneration  with  hemorrhagic  and 


ORIGINAL  COMMUNICATIONS  195 

anemic  necrosis  around  the  small  portal  vessels  and  a  fatty- 
degeneration  of  the  periphery  of  the  lobules,  resembling 
acute  yellow  atrophy.  Kidney  lesions  also  appear  in  prac- 
tically all  cases  of  eclampsia,  cloudy  swelling  and  fatty  de- 
generation of  epethelium  are  the  rule.  These  changes  are 
believed  by  most  authorities  to  be  secondary  to  liver  changes. 

Circulatory  system — The  ventricles  are  contracted,  the 
auricles  full  of  dark-red  blood,  which  does  not  clot  readily. 
Heart  muscle  is  fatty  with  tiney  hemorrhages,  necrosis,  and 
thrombi ;  it  tears  easily.  Thrombi  and  emboli  are  very  com- 
mon in  the  fine  vessels  of  the  lungs,  liver,  kidney,  brain,  and 
skin.  Microscopic  findings  in  blood  are  not  constant. 
Marked  leucocytosis,  the  multinuclear  predominating,  is 
sometimes  found.  Congestion  and  edema  of  lungs  are  usu- 
ally shown. 

Symptoms — Eclampsia  may  attack  a  pregnant  woman, 
who  has  apparently  been  in  good  health  up  to  the  moment 
of  the  onset.  However,  this  is  not  the  rule.  Prodromal  symp- 
toms exist  from  a  few  hours  to  several  weeks  before  the 
seizure.  Severe  headache,  frontal  or  occipital,  dizziness,  dis- 
turbances of  vision,  and  sometimes  complete  blindness  from 
edema  or  albuminuric  retinitis.  Puffiness  of  eyes  and  cheeks 
and  upper  extremities,  insomnia  or  inclined  to  sleep.  Ner- 
vousness, twitching  of  muscles,  cramps,  epigastric  pain, 
nausea,  and  vomiting,  tenderness  over  pit  of  stomach  and 
liver.  High  blood  pressure  and  accentuated  2d  heart  sound. 
Urine  is  usually  diminished;  high  specific  gravity  and  low 
in  urea  output  and  total  solids.  Albumin  with  hyaline  and 
granular  casts. 

The  convulsions  are  epileptiform  in  character  and  con- 
sist of  a  stage  of  tonic  followed  by  a  stage  of  clonic  con- 
tractions. Patient  becomes  unconscious,  pupils  dilate,  eyes 
and  head  turn  to  one  side,  usually  left,  mouth  opens  and 
tongue  protrudes,  and  there  may  be  a  cry  or  sigh.  Then 
comes  a  brief  period  of  tonic  contraction  in  which  respira- 
tion ceases  and  patient  is  cyanotic.  This  stage  lasts  about 
one-half  minute  or  less  and  is  followed  by  general  clonic 


196       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

contractions  involving  all  the  voluntary  muscles.  (During 
this  stage  she  should  have  especial  care  to  protect  from  in- 
jury, but  should  not  be  forcibly  held.)  Slight  respiratory 
movements  now  occur  and  the  cyanosis  gradually  disap- 
pears. This  stage  lasts  about  three  minutes  and  is  followed 
by  coma  for  a  brief  period  in  some  cases  while  in  others  it 
exists  until  the  onset  of  another  convulsion.  In  favorable 
cases  the  woman  wakes  in  from  thirty  minutes  to  an  hour 
bewildered  and  with  severe  muscular  soreness.  In  a  little 
while  if  she  is  to  have  more  the  attack  comes  again.  In  the 
serious  cases  the  attacks  come  even  more  frequently  than 
thirty  minutes. 

During  the  attack  temperature  rises,  pulse  becomes  rapid, 
blood  pressure  very  high  and  urine  suppressed  or  dimin- 
ished. It  frequently  contains  blood,  and  nearly  always  albu- 
min, so  much  that  it  almost  solidifies  on  boiling. 

Pains  usually  begin  if  the  convulsions  are  severe,  or  if 
they  come  during  labor  it  is  usually  terminated  rapidly. 
After  labor  the  cases  are  usually  more  favorable.  However, 
pregnancy  is  not  always  interrupted  by  eclampsia  and  it  is 
not  always  necessary  to  terminate  pregnancy  in  the  treat- 
ment. De  Lee  reports  the  delivery  of  a  living  child  in  which 
the  mother  had  two  seizures  within  three  weeks'  time,  and 
the  convulsions  so  severe  that  the  jaw  was  dislocated. 

More  usually  the  attack  kills  the  fetus,  the  symptoms 
abate  and  the  product  is  expelled  in  due  time. 

Diagnosis — It  must  be  differentiated  from  epilepsy,  hys- 
teria and  convulsions  or  coma  due  to  cerebral  diseases,  dia- 
betes or  acute  poisoning.  Anemic  convulsions  can  hardly  be 
differentiated,  but  the  general  line  of  treatment  is  about  the 
same. 

Epilepsy  is  eliminated  by  history  of  previous  attacks,  the 
contracted  pupils,  diminished  or  absent  reflexes.  The  uri- 
nary findings,  low  blood  pressure  and  absence  of  fever. 

Hysteria,  by  the  atypical  convulsive  seizure,  length  of 
time  it  lasts,  spastic  contraction  of  muscle  groups,  mobile 


ORIGINAL  COMMUNICATIONS  197 

pupils,  absence  of  cyanosis,  stertorous  breathing,  or  urinary 
findings. 

Spinal  puncture  may  be  required  to  differentiate  the  or- 
ganic diseases  of  brain,  and  history  of  case  usually  excludes 
poisons. 

Prognosis  is  always  serious,  both  for  mother  and  child. 
Over  20  per  cent  of  women  die.  Mortality  is  higher  in  mul- 
tipara than  in  primipara.  The  greater  the  number  of  fits  the 
higher  the  mortality,  being  50  per  cent  in  cases  where  there 
has  been  over  twenty  convulsions.  It  is  also  graver  when 
the  convulsions  and  coma  are  prolonged  with  rising  tem- 
perature and  diminished  urine.  Mortality  is  highest  during 
pregnancy  and  least  during  puerperium.  Death  results  from 
coma,  hemorrhage  into  brain  or  pulmonary  edema. 

In  severe  cases  which  recover  prolonged  mental  symp- 
toms may  continue  and  even  insanity  result,  or  if  hemor- 
rhage has  occurred,  a  paralysis. 

Fetal  mortality  is  infiuenced  by  period  of  gestation,  at  7 
months  it  is  almost  100  per  cent,  becoming  less  as  term  is 
approached.  At  best  it  is  40  to  50  per  cent,  causes  of  death 
being  prematurity,  toxemia,  asphyxiation,  drugs  adminis- 
tered to  mother  and  injuries  sustained  during  birth,  espec- 
ially in  forced  deliveries. 

Treatment — There  is  no  routine  treatment  of  eclampsia, 
the  cases  vary  so  in  severity.  All  pregnant  women  should 
be  looked  on  as  subjects  of  eclampsia,  and  if  they  are 
watched  carefully  the  condition  can  be  prevented  in  the  ma- 
jority of  instances. 

The  rules  of  the  hygiene  of  pregnancy  should  be  strictly 
followed.  Always  on  the  lookout  for  evidences  of  toxemia, 
urine  should  be  examined  at  least  every  three  or  four  weelc? 
during  first  six  months  and  every  two  weeks  during  last 
three  months,  and  if  patient  is  not  doing  well,  weekly  or 
even  daily  examinations  should  be  made.  Albuminuria  is 
most  important  finding  and  is  never  marked  without  evi- 
dences of  toxemia.  Diminished  daily  amount  of  solid  and 
output  is  next  in  importance.     Casts,  unless  granular  or 


198        NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

cellular,  are  of  little  significance,  and  the  percentage  of  urea 
is  not  reliable  unless  associated  with  albuminuria.  A  rising 
blood  pressure  is  a  warning  but  is  considered  safe  under 
150  m.  m. 

When  first  symptoms  of  toxemia  appear,  treatment  must 
be  instituted  at  once ;  diet  regulated  so  that  least  nitrogen- 
ous food  possible  is  given.  Milk,  vegetables,  and  fruits 
given  with  large  amounts  of  water,  unless  there  is  consid- 
erable edema  and  heart  already  overloaded.  Stimulate  em- 
unctories,  plenty  of  fresh  air  and  rest.  If  symptoms  do  not 
subside  under  this  and  patient  grows  progressively  worse 
with  convulsions,  then  the  treatment  is  surgical,  according 
to  a  number  of  authorities,  while  others  still  hold  to  the  me- 
dicinal plan  and  treat  expectantly  for  a  short  time,  not  usu- 
ally over  forty-eight  hours. 

Straganaff's  treatment  is  expectancy  with  narcotics.  Pa- 
tient is  placed  in  a  quiet  room  disturbed  as  little  as  possible, 
given  14  gr.  morphine  by  hypo,  and  30  gr.  chloral  by  rectum 
every  three  hours,  according  to  indication,  which  is  convul- 
sions. For  each  internal  examination,  catheterization  or 
enema  and  convulsions,  chloroform  or  ether  is  given. 

Venesection  and  saline  solutions,  catharsis,  hot  packs,  and 
toxin.  If  patient  grows  worse  operative  delivery  is  per- 
formed. Veratrum  viride,  thyroid  extract,  para  thyroid  ex- 
tract, alkalies,  amyl  nitrate,  lumbar  puncture,  all  have  their 
advocates  in  expectant  treatment,  but  all  agree  in  terminat- 
ing pregnancy  if  patients  do  not  improve  in  short  time. 

Deebhsen's  dictum  is,  after  first  convulsion,  put  patients 
under  anesthetic  and  deliver  at  once,  and  statistics  show  that 
rapid  emptying  of  uterus  after  first  convulsion  gives  best  re- 
sults. Peterson,  collecting  615  cases  of  early  delivery,  as 
soon  as  possible  after  first  convulsion,  showed  mortality  of 
15.9  per  cent,  as  compared  to  28.9  per  cent  treated  conserva- 
tively. R.  Friend  reports  from  Berlin  charity  551  cases  de- 
livered within  one  hour  after  convulsion  with  no  mortality. 

Another  advantage  of  early  delivery  is  that  more  children 
are  saved.     Methods  of  delivery  depend  first  on  period  of 


ORIGINAL  COMMUNICATIONS  199 

pregnancy;  second,  environment  of  patient;  third,  state  of 
cervix;  fourth,  extraneous  complications,  as  contracted  pel- 
vis, tumors,  placenta  previa,  etc. ;  fifth,  skill  of  the  attendant. 
If  cervix  is  dilated,  forceps  should  be  applied  and  delivery 
accomplished  at  once.  In  hard,  rigid  cervix,  vaginal  or  ce- 
sarian  section,  some  claiming  latter  the  better  operation,  be- 
ing quicker  and  with  less  shock,  while  others  claim  the  same 
for  the  first. 

Ether  is  the  anesthetic  preferred  and  as  little  as  possible 
should  be  given. 

In  closing,  I  wish  to  make  a  plea  for  better  attention  to 
pregnant  women  so  that  not  only  eclampsia,  but  other  toxe- 
mias and  complications  may  be  noted  and  the  pregnant 
woman  carried  to  confinement  under  the  most  favorable 
conditions  possible. 


200       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERt 


BtktUh  ArttrbH 


INFLUENZA.* 


0.  A.  SCHMID.,  M.D., 

St.  Joseph,  Mo. 


Not  since  Pfeiffer  isolated  the  influenza  bacillus  in  1892 
has  a  disease  term  been  so  widely  used  and  misused,  and  be- 
cause the  disease  is  so  varied  in  its  form  and  clinical  mani- 
festations is  this  misuse  apparent.  Therefore  we  can  find 
no  more  appropriate  subject  for  discussion  and  study  at  this 
time.  Holt  and  Wollstein  in  their  investigations  say  that 
we  can  consider  as  influenza  only  those  cases  in  which  the 
bacillus  of  Pfeiffer  are  found.  Yet  the  folly  of  such  prac- 
tice is  at  once  brought  to  notice  when  we  consider  that  the 
Pfeiffer  bacillus  is  not  easily  isolated  either  in  blood  culture 
or  from  the  secretions  and  can  often  be  found  in  quantities 
in  supposed  normal  individuals.  For  instance,  these  inves- 
tigators discovered  the  organisms  in  85  persons  of  whom 
42  were  suspected  of  having  influenza  and  43  were  not — 15 
of  the  latter  were  nurses  and  physicians  in  intimate  contact 
with  patients  suffering  from  the  disease.  I  take  it  for 
granted  that  the  latter  43  were  not  having  symptoms  of  any 
sort.  I  have  tried  during  the  present  epidemic  (in  a  rough 
wa3%  I  admit) ,  to  find  the  bacillus  in  the  secretions  and  out 
of  25  cases  in  which  I  made  the  attempt  found  them  in  but 
two. 

Most  authorities  describe  the  disease  in  types  depending 
upon  the  localization  of  the  toxins.  Leichtenstern's  classi- 
fication is  as  follows:     1.  The  purely  toxic  variety  which  is 

*Read  before  the  Buchanan  Medical  Society,  St.  Joseph,  January  5, 
1915. 


SELECTED  ARTICLES  201 

subdivided  into:  (a)  Simple  influenza  fever;  (b)  the  ner- 
vous form.  2.  Toxic  inflammatory  (a)  The  catarrhal  res- 
piratory; (b)  gastro-intestinal. 

Osier's  classification  is  a  more  usual  one:  1,  respiratory; 
2,  gastro-intestinal;  3,  nervous,  and  4,  febrile. 

The  usual  English  classification  is  as  follows :  Simple  ca- 
tarrhal fever;  catarrhal  fever  with  pulmonary  complica- 
tions; and  fever  with  abdominal  complications.  But  back 
as  far  as  in  the  epidemic  of  1848  Peacock  stated  that  he 
found  influenzal  fever  with  catarrhal  symptoms  and  even 
influenza  without  fever.  Peacock's  findings  are  plainly  evi- 
dent at  the  present  time.  Therefore,  the  latter  classification 
is  useless.  A  study  of  848  cases  of  influenza  recorded  at  the 
Massachusetts  General  Hospital  showed  the  majority  to  be 
of  respiratory  type  while  a  large  number  of  patients  at  en- 
trance so  simulated  typhoid  that  they  were  placed  on  enteric 
precautions. 

All  forms  of  the  disease  show  certain  symptoms  and  fea- 
tures in  common  and  yet  these  symptoms  are  so  various  in 
each  case  that  it  will  be  convenient  to  describe  first  of  all, 
the  usual  or  simple  catarrhal  influenza  may  present  symp- 
toms that  are  common  to  the  various  types ;  therefore,  it  will 
be  necessary  to  resort  to  considerable  repetition  later  on 
when  describing  the  disease  under  its  classifications. 

The  first  and  most  striking  symptoms  about  influenza  in 
all  its  forms  is  the  suddenness  of  attack.  I  have  seen,  dur- 
ing the  past  few  weeks  symptoms  and  symptom  groups 
which  T  did  not  realize  were  possible  in  this  disease,  namely : 

Mrs.  J.,  age  42,  in  good  health,  arose  one  morning  with 
apparently  nothing  wrong  and  prepared  the  usual  morning 
meal  and  of  a  sudden  relatives  about  the  house  noticed  her 
acting  strangely.  She  suddenly  became  maniacal  and  this 
lasted  several  hours,  and  then  she  went  through  the  usual 
course  of  a  very  severe  influenzal  attack. 

Mr.  N.,  salesman,  left  his  home  feeling  well  and  stepped 
into  his  machine  for  a  ride,  and  after  being  out  not  more 
than  twenty  or  twenty-five  minutes,  was  suddenly  attacked 


202        NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

with  violent  headache  and  lumbar  pains  and  was  unable 
to  drive  his  machine  home.  He  had  to  be  assisted  from  same. 
He  then  went  through  a  severe  clinically  influenza. 

In  no  few  cases  do  we  see  som.e  mild  delirium  which  is 
rather  sudden  of  onset.  Goodhart,  of  England,  states  that 
he  saw  a  case  in  which  the  patient,  while  out  driving,  with- 
out warning  or  previous  complaint,  fell  from  his  cart  in  an 
insensible  condition;  was  picked  up,  put  into  the  cart,  and 
he  himself  drove  home,  and  although  he  had  a  broken  rib, 
was  so  dazed  he  insisted  on  retiring  without  removing  his 
clothes  and  was  thought  to  be  drunk.  Another  case  he  re- 
cites was  that  of  a  medical  man,  who,  on  going  to  bed  in  his 
usual  health  arose  during  the  night  to  void  urine  fell  to  the 
floor  and  required  assistance  to  get  to  bed  again,  after  which 
he  went  through  a  severe  form  of  influenza. 

But  in  the  usual  case  our  patient  presents  himself  with 
the  statement  that  he  was  suddenly  attacked  with  violent 
pains  of  bones  and  muscles  over  entire  body ;  but  lays  espec- 
ial stress  upon  the  peculiar  pains  in  back  over  lumbar  region 
and  of  such  character  as  to  remind  one  that  he  is  dealing 
with  the  prodromal  back  pains  of  variola.  There  are  also 
frontal  and  occipital  pains  in  head,  which  are  intensified 
upon  movement  of  head  from  backward  and  forward  posi- 
tion, or  on  stooping,  reminding  one  of  a  frontal  sinus  in- 
volvement. There  is  also  complaint  of  pressure  and  full- 
ness in  the  head;  of  dizziness  and  pain  in  eyeballs.  The 
chest  pains  complained  of  are  usually  the  same  in  all  cases, 
viz.: 

The  patient  will  describe  a  course  about  the  abdomen  indi- 
cating the  attachments  of  the  diaphragm.  He  also  places 
his  hand  over  the  sternum  and  explains  that  the  pains  are 
there.  And  states  that  all  these  pains  are  deeply  seated  and 
that  he  is  afraid  he  has  pneumonia.  Usually  about  the  same 
time  a  profuse  coryza  and  watery  eyes.  The  patient  is  often 
interrupted  in  narrating  his  complaint  by  a  fit  of  uncon- 
trollable harsh,  dry,  brassy  cough.  While  these  things  are 
occuring  he  has  chilly  sensations,  especially  up  and  down 


SELECTED  ARTICLES  203 

the  spine.  Often  the  patient  will  say  that  he  can  place  his 
hand  over  a  spot  on  his  back  which  is  constantly  cold.  There 
are  paroxysms  of  inward  burning  sensations.  A  day  or  two 
later  he  may  have  a  series  of  violent  chills.  But  there  is  no 
regularity  of  onset  of  these  chills  and  in  fact  in  most  of  my 
recent  cases  they  came  on  after  two  or  three  days  of  tem- 
perature. 

The  tongue  presents  a  thick  heavy  coat  and  is  itself  thick 
and  tremulous  and  indented  by  the  teeth.  The  breath  has  a 
peculiarly  offensive  odor  and  there  is  nausea,  sometimes 
vomiting.  Patient  complains  that  he  does  not  care  for 
nourishment;  and  when  he  does  partake  of  same,  says  it 
does  not  smell  or  taste  as  it  should  and  often  complains  there 
is  no  taste  at  all.  The  patient  suffers  from  a  sudden  pros- 
tration altogether  out  of  proportion  to  the  duration  or  ap- 
parent severity  of  his  illness. 

The  temperature  in  influenza  is  as  varied  as  the  other 
symptoms  and  in  no  other  infectious  disease  is  there  a 
greater  temperature  range.  A  great  many  have  subnormal 
temperatures  in  the  very  beginning.  I  now  have  a  patient 
running  a  temperature  of  96  to  97  F.  Others  range  from 
normal  temperature  to  that  of  103  deg.,  which  continues 
from  three  to  six  days  and  then  subsides,  leaving  the  patient 
as  weak  and  depressed  as  if  he  had  gone  through  an  ex- 
tended serious  illness.  Oftentimes  there  occurs  great  body 
loss.  Few  cases  have  a  tendency  to  recurrence  of  fever. 
About  the  time  the  temperature  has  subsided  there  begin 
drenching  sweats  which  last  for  several  days,  and  have  an 
odor  similar  to  that  of  an  extremely  septic  condition.  Dur- 
ing the  height  of  the  attack,  I  have  found  some  who  were 
extremely  drowsy,  this  existing  especially  in  children.  I 
had  one  case  in  a  dentist's  family  in  which  the  child  slept 
almost  continually  for  two  days  and  the  doctor  called  up  and 
asked  whether  or  not  medication  contained  a  narcotic. 

The  foregoing  is  the  symptom  complex  as  they  might  oc- 
cur singly  or  all  in  any  simple  catarrhal  case  even  when  no 
com^plications  exist,  and  these  symptoms  may  be  quite  alarm- 


204        NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

ing.  This  brings  us  to  the  disease  under  its  various  forms. 
The  Respiratory  Form — This  is  by  far  the  most  common 
form  of  the  disease,  but  the  question  often  arises  whether 
or  not  this  additional  symptom  and  pathology  is  a  part  of 
influenza  or  is  a  complication  thereof.  In  this  form  there 
is  the  usual  harsh,  dry  cough.  The  pharynx  shows  a  highly 
congested  condition,  and  while  there  may  be  no  evidences 
of  pneumonia,  the  air  seems  to  enter  the  small  bronchi  very 
badly.  There  may  be  even  loud  bronchial  rales  indicating 
some  congestion.  This  is  the  usual  simple  catarrhal  type  of 
moderate  severity.  Take  these  symptoms  and  add,  scat- 
tered or  even  localized,  areas  of  dullness — sometimes 
amounting  to  almost  absolute  flatness  on  percussion — with 
these  areas  full  of  loud  sticky  rales  that  makes  one  sure  he 
is  dealing  with  an  acute  pneumonia.  Often  with  flushed 
cheeks  and  high  temperature,  but  not  an  extremely  high 
respiratory  rate,  but  with  respiration  somewhat  embar- 
rassed and  one  deals  with  a  severe  pulmonary  type  of  in- 
fluenza. This  condition  will  often  increase  in  intensity  and 
extend  over  a  whole  lung  or  considerable  portion  of  it.  De- 
lirium supervenes  and  the  pulse  mounts  up  and  the  case 
terminates  fatally  without  any  physical  evidence  of  consoli- 
dation being  present.  Oftentimes  we  will  find  areas  of  dull- 
ness with  rales,  with  high  temperature,  and  rapid  respira- 
tion and  find  on  the  next  day  that  these  symptoms  have  dis- 
appeared, viz. : 

Miss  D.,  age  25,  on  afternoon  of  December  22,  while  out 
shopping  suddenly  began  coughing  and  complaining  of  se- 
vere headache.  She  returned  to  her  home  and  that  evening 
complained  of  severe  chest  pains  and  soon  had  a  severe  chill. 
I  was  summoned  hurriedly,  relatives  stating  that  patient 
had  difficulty  in  breathing.  Temperature  102.6  F.,  pulse 
100,  respiration  22.  Physical  examination  of  chest  showed 
the  entire  right  side,  posteriorly  and  anteriorly,  dull  on  per- 
cussion, in  fact  nearly  absolute  flatness,  breath  sounds  bare- 
ly audible,  or  not  at  all  in  some  areas.  Occasionally  loud 
rale  over  apex.    High  in  the  axilla  I  found  a  slight  indistinct 


SELECTED  ARTICLES  206 

pleuritic  rub.  I  felt  sure  I  was  dealing  with  a  pleurisy  with 
an  effusion  and  told  the  family  so.  I  returned  the  next 
morning  prepared  to  aspirate  to  confirm  my  diagnosis.  I 
found  the  chest  signs  very  much  improved  and  dullness 
somewhat  lessened.  I  decided  to  wait  with  the  aspiration, 
and  that  evening  found  the  chest  signs  entirely  cleared  up 
with  the  exception  of  a  few  bronchial  rales.  Patient  went 
through  a  moderately  severe  clinically  influenzal  attack  and 
a  few  days  later  was  up  and  about,  despite  my  advice. 

It  is  in  cases  under  this  head  that  we  often  find  a  severe 
laryngitis  with  complete  loss  of  voice;  with  a  complaint  of 
severe  lancinating  pains  in  throat. 

Expectoration  is  usually  scanty  at  first  and  later  becomes 
profuse  and  of  a  mucopurulent  character  and  often  blood- 
streaked.  Actual  hemorrhages  may  occur  without  previous 
signs  of  pulmonary  condition  being  present.  I  have  seen 
one  case  expectorate  a  considerable  amount  of  blood  and 
careful  examination  of  chest  following  recovery  of  disease 
showed  no  signs  of  other  trouble.  According  to  some  inves- 
tigators, the  influenza  bacilli  alone  were  found.  Others 
found  pneumococci.  Giving  rise  to  the  argument  that  in 
some  cases  we  are  dealing  with  complications  and  not  the 
primary  disease.  Yet  when  we  consider  that  on  the  very 
day  that  the  patient  first  notices  his  illness,  which  is  clini- 
cally a  true  influenza,  with  the  influenza  bacillus  present  in 
the  secretions,  and  we  find  these  symptoms  on  the  first  day 
or  two  after  onset  we  must  believe  that  the  complaint  is  the 
primary  disease  and  that  we  have  not  had  time  for  such 
severe  complications  to  take  place. 

Gastro-Intefttinal  Tijpe — In  this  type  of  the  disease  we 
have  accompanying  the  usual  symptoms  of  the  disease  either 
a  severe  constipation  which  is  the  rule,  and  is  very  obsti- 
nate or  rarely  a  diarrhea.  There  is  complete  loss  of  appe- 
tite and  the  tongue  is  more  coated  than  the  average  simple 
case.  In  a  few  I  have  seen  a  very  red  tongue  with  patches 
of  grayish  spots  and  sometim.es  a  tongue  very  near  a  straw- 
berry type.     The  patient  complains  of  some  tender  points 


206        NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

over  abdomen  and  there  is  some  tympanites.  There  is  ex- 
treme nausea,  seldom  vomiting.  In  not  a  few  of  these  cases 
one  is  reminded  that  he  may  possibly  be  dealing  v^ith  a  ty- 
phoid patient  because  of  the  drowsiness  and  headache  and 
severe  pains  in  gastric  region  with  occasional  blood-streaked 
stools  and  feeling  described  as  emptiness.  The  Germans 
report  observations  in  which  Peyer's  patches  and  mesenteric 
glands  were  swollen.  Ulceration  of  the  jejunum  has  been 
reported  by  Kuskow.  The  influenza  bacilli  were  isolated 
from  the  pus  of  an  appendix  abscess  by  Adrin.  Fisch  and 
Hill  have  reported  a  case  of  purulent  peritonitis  with  isola- 
tion of  the  influenza  bacillus  in  pure  culture. 

Nervous  Type — Of  this  type  I  have  had  very  little  expe- 
rience, except  in  the  case  of  acute  mania  already  cited.  In 
addition  to  the  headache  delirium,  there  is  restlessness  and 
insomnia.  Cases  have  been  reported  with  hemiplegia,  mye- 
litis, encephalitis  and  paralysis,  and  more  frequently  with 
neuralgia  and  multiple  neuritis.  And  according  to  Leich- 
tenstern's  report  of  such  cases,  scarcely  any  portion  of  the 
nervous  system  escaped  injury  from  the  influenza  bacillus 
and  its  toxins. 

Complications  and  Sequela — Of  the  complications,  pneu- 
monia is  the  most  dangerous  and  is  most  frequent  and  may 
be  broncho  or  lobar.  In  broncho  pneumonia  as  in  most  cases 
of  such,  a  very  close  examination  must  be  made,  because  the 
areas  of  consolidation  are  often  so  small  that  areas  of  dull- 
ness may  be  overlooked.  I  have  already  spoken  of  the  fre- 
quency of  multiple  areas  of  consolidation.  In  eleven  fatal 
cases  reported  by  Smith,  bacilli  of  Pfeiffer  were  found  in 
the  exudate,  in  culture,  and  sections  of  the  pneumonic  foci ; 
in  one  case  four  lobes  shov/ed  foci  of  consolidation,  three 
lobes  three  times,  two  lobes  once  and  one  lobe  six  times.  The 
right  upper  lobe  was  involved  in  five  cases. 

Cardiac  Involvemeyit — Just  where  to  place  the  frequent 
heart  involvement  that  often  follows  influenza  (since  they 
are  found  in  apparently  simple  cases,  but  most  often  they 
follow  the  respiratory  form),  remains  a  question.    The  pa- 


SELECTED  ARTICLES  207 

tient  presents  no  stethoscopic  signs  or  symptoms  of  cardiac 
involvement,  except  that  he  complains  of  occasional  sharp 
pains  around  cardiac  regions.  Often  one  finds  an  accen- 
tuated first  sound  but  usually  aJl  sounds  are  normal.  It  is 
later  that  the  symptoms  of  cardiac  involvement  presents 
themselves  as  follows:  There  is  a  feeble,  irregular,  rapid 
pulse.  The  cardiac  area  is  not  increased  on  percussion,  but 
the  sounds  are  indistinct.  There  is  after  this,  a  faint  feeling 
accompanied  by  considerable  pallor.  After  several  days 
rest  and  patient  makes  attempt  to  get  out  of  his  bed  because 
of  his  feeling  much  better,  he  finds  he  becomes  faint  again 
and  pulse  often  mounts  up.  In  some  cases  I  have  found  a 
rather  low  pulse,  one  ranging  from  50  to  60  and  patient 
feeling  very  weak. 

Complications  of  meningitis  and  nephritis  are  rare.  In- 
fections of  the  joints  have  been  reported  in  which  the  influ- 
enza bacillus  was  found.  Sometimes  we  see  chronic  bron- 
chitis and  even  chronic  influenza  following  acute  attacks, 
and  of  course,  as  we  all  know,  we  have  those  frequent  com- 
plications as  otitis  media  and  abscesses  in  the  nasal  acces- 
sory sinuses. 

In  fact,  when  we  speak  of  the  complications  and  different 
types  of  influenza,  it  seems  to  me  that  we  may  have  mani- 
festations or  complications  of  any,  or  all  mucous  or  serous 
surfaces  and  even  some  of  the  glandular  structures  may  be 
involved.  (And  unless  we  can  get  a  definite  bacteriological 
diagnosis  it  is  often  the  question  whether  we  are  dealing 
with  complications  or  the  disease  itself  with  local  manifes- 
tations.) 

Diagnosis — The  diagnosis  of  influenza,  in  a  great  major- 
ity of  cases  usually  presents  no  difficulty.  Usually  we  see 
the  disease  during  an  epidemic.  The  abrupt  onset  with 
alternating  flashes  of  heat  and  chilliness  is  typical  and  aids 
us  in  our  diagnosis.  Then  there  are  the  severe  aching,  the 
soreness  of  eyeballs  and  headache  and  distressing  pains  over 
the  body.  If  doubtful,  the  bacillus  should  be  looked  for  in 
the  sputum  and  the  secretions. 


208        NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Influenza  is  the  dumping  ground  for  diagnosis  of  many 
obscure  symptoms  and  it  is  here  that  I  want  to  state  the  mis- 
use of  the  term.  Whenever  we  get  a  history  of  malaise, 
chilly  sensations  and  muscular  soreness  with  headache,  there 
is  a  tendency  to  immediately  think  of  influenza  and  such 
practice  is  not  only  unscientific  but  can,  and  often  does,  lead 
to  serious  error  and  grief  to  the  attending  physician.  The 
warning  can  not  be  too  frequently  given  that  any  beginning 
sepsis  or  localized  abscess  formations  may  present  such 
prodromal  symptoms.  Another  fault,  and  a  serious  and 
most  frequent  fault  in  our  diagnosis,  is  that  we  are  inclined 
to  call  every  severe  cold  and  coryza,  influenza,  and  it  is  here 
again  that  the  misuse  is  apparent.  How  many  acute  exac- 
erbations of  tuberculous  origin  are  called  influenza.  I  be- 
lieve that  when  a  patient  presents  himself  with  a  history  of 
malaise,  and  achy  pains  over  chest  and  shoulders,  with  pos- 
sibly some  dull  headache  and  chilly  sensations,  and  with  fre- 
quent persistent  paroxysm  of  coughs,  we  frequently  make 
serious  error  in  immediately  diagnosing  our  case  as  influ- 
enza without  a  thorough  examination  of  the  chest.  When- 
ever a  patient  presents  himself  with  the  above  symptoms 
and  tells  me  that  he  has  had  three,  four  or  even  five  such  at- 
tacks, I  look  with  suspicion  upon  the  case  and  inquire  min- 
utely into  the  history  of  such  attack,  and  closely  examine 
the  lungs  and  many  times  have  I  found  such  cases  to  be  of 
slow  progressing  tubercular  process.  Yet  when  I  make  such 
argument,  I  must  admit  I  have  seen  cases  wherein  the  his- 
tory showed,  and  where  I  have  often  seen  one  member  of 
family  who  had,  what  appeared  to  be,  nothing  but  an  ordi- 
nary cold  or  coryza  and  within  three  to  four  days  see  one  or 
more  members  of  same  family  have  a  very  severe  form  of 
influenza.  Such  occurrences,  when  seen  so  often,  makes  one 
believe  the  ordinary  cold  was  caused  by  the  Pfeiff'er  bacillus. 

The  differential  diagnosis  from  typhoid,  it  seems  to  me, 
should  offer  no  serious  obstacle,  since  in  influenza  our  tem- 
perature record  is  of  short  duration  and  is  not  the  charac- 
teristic typh()i(i  temperature.     If  in  case  the  temperature 


SELECTED  ARTICLES  209 

should  persist  and  be  high,  a  Widal  should  clear  up  our  diag- 
nosis. Again  the  bacillus  of  Pfeiffer  should  be  looked  for 
in  the  bronchial  and  nasal  secretion.  Pneumonia  is  often 
the  stumbling  block  in  the  diagnosis  of  influenza  and  has 
frequently  been  mistaken  for  such,  when  the  chest  signs 
have  been  unusually  severe.  But  pneumonia  is  usually  uni- 
lateral, while  in  influenza,  the  symptoms  are  usually  bilat- 
eral. In  the  former  there  is  usually  a  larger  and  more  dis- 
tinct area  of  dulness  and  is  usually  confined  to  one  lobe  or 
area,  while  in  influenza  we  niay  have  scattered  areas  of  dull- 
ness. In  the  former,  also,  there  are  more  distinct  rales, 
while  in  influenza,  the  rales  are  not  of  a  subcrepitant  char- 
acter and  are  not  constant  and  usually  clear  up  within  24 
to  48  hours. 

Etiology — Etiology  of  influenza  has  been  found,  and  is 
generally  accepted  today  as  the  bacillus  of  Pfeiffer.  But 
this  remains  in  doubt  to  some  because  the  bacillus  has  been 
frequently  found  in  quantities  in  fatal  cases  of  measles, 
diphtheria,  and  scarlet  fever,  and  similar  organisms  have 
been  found  in  conjunctivitis  and  whooping  cough.  Even  in 
patients  suffering  from  influenza  clinically,  often  the  influ- 
enza bacillus  is  not  found,  and  this  has  had  a  tendency  to 
increase  this  doubt.  Cushman,  in  an  epidemic,  reported  the 
presence  of  the  pneumococcus  in  46  out  of  49  cases,  and  so 
all  sorts  of  cocci  have  been  reported  found  in  acute  infec- 
tins  resembling  influenza.  Therefore,  because  of  doubtful- 
ness of  our  bacteriological  findings,  we  are  still  in  the  dark 
relative  to  a  true  diagnosis  in  a  great  many  cases  resembling 
influenza.  Clinicians  are  described  under  three  heads,  de- 
pending upon  the  stand  they  may  take  relative  to  v/hat  part 
the  influenza  bacillus  may  play  as  to  the  cause  of  the  disease, 
viz.,  those  who  call  any  acute  cold  influenza ;  secondly,  those 
dwelling  upon  the  widespread  occurrence  of  the  bacillus  in 
other  diseases.  Even  when  they  find  the  influenza  bacillus 
in  the  secretions  of  the  suspected  case,  questions  whether 
these  bacilli  may  not  be  saprophytes,  and  hesitate  to  call  the 
disease  influenza.     The  third  are  those  who  take  the  stand 


210        NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

that  where  the  influenza  bacillus  is  found,  there  is  influenza. 

Yet  we  must  recognize  when  we  pursue  the  findings  of 
some  investigators  that  many  of  our  cases  of  influenza  are 
truely  caused  by  the  influenza  bacillus  alone.  Horder  re- 
ports a  case  of  endocarditis  in  which  the  influenza  bacillus 
was  isolated  from  the  blood  four  times  during  the  interval 
of  six  weeks.  The  influenza  bacilli  were  again  isolated  from 
the  valve  in  pure  culture  at  autopsy.  Ghedini  cultivated  this 
organism  from  the  blood  in  eighteen  cases  out  of  twenty- 
eight  and  from  fourteen  spleen  punctures,  found  the  bacilli 
in  eight.  He  insists  that  the  blood  culture  must  be  taken 
during  the  fever  period.  The  disease  occurs  in  epidemics 
and  pandemics  and  seems  every  so  often,  as  every  ten  to 
fifteen  years,  to  sweep  the  whole  country.  In  such  epidem- 
ics as  1892  occasionally  sweeps  the  world.  Every  quarter  of 
the  globe  has  been  visited  by  the  disease.  Influenza  is  not 
a  new  disease,  since  it  was  described  in  England  as  far  back 
as  1650  when  it  swept  England  with  about  the  same  charac- 
teristics as  our  present  epidemic. 

Modes  of  Coyiveyance — The  disease  usually  follows  the 
ordinary  lines  of  human  and  commercial  travel  and  is  un- 
doubtedly communicable  by  contagion.  Just  what  the  mode 
of  entrance  of  the  bacillus  into  the  body  is,  is  not  yet  known, 
but  it  is  undoubtedly  through  the  respiratory  tract.  Some 
believe  that  the  primary  point  of  infection  is  often  the  con- 
junctiva, others  pretend  that  the  alimentary  canal  is  the 
host  of  the  bacillus. 

Predisposing  Causes — All  persons  are  susceptible  to  the 
contagion.  Age  has  some  influence,  the  period  of  greatest 
susceptibility  being  from  the  twentieth  to  the  thirtieth  year, 
the  very  young  are  least  susceptible.  Those  whose  vitality 
has  been  lowered  by  some  chronic  affections  are  usually  the 
most  susceptible. 

Immnnity — None  are  immune  from  influenza  and  one  at- 
tack seems  to  predispose  to  another,  since  it  is  very  frequent 
to  find  reoccurrences  with  each  epidemic. 


SELECTED  ARTICLES  211 

Prognosis — The  prognosis  is  usually  good  in  the  milder 
forms.  The  fatalities  occurring  in  most  parts  in  the  res- 
piratory form  and  in  complications  with  pneumonia  and  the 
heart.  It  acts  very  severely  in  those  individuals  suffering 
from  tuberculosis,  valvular  disease  of  the  heart,  and  in  neph- 
ritis.   The  average  death  rate  being  about  2  per  cent. 

Treatment — Prophylaxis — No  drug,  so  far  known,  is  of 
prophylactic  value.  Urotropin  is  said  to  be  of  value  as  a 
prophylactic,  but  this  is  very  questionable  unless  it  would 
be  so  in  regards  to  the  meninges  and  the  spinal  canal.  I 
have  given  it  in  a  few  exposed  to  the  disease  and  found  two 
who  had  taken  it  that  developed  moderately  severe  cases  of 
influenza. 

In  the  study  of  one  pandemic,  according  to  Smith,  it  was 
shown  that  new  districts  became  infected,  when  visited  by 
persons  with  the  disease. 

Parsons  reports  that  of  several  thousand  persons  engaged 
in  deep  sea  fishing  in  the  North  Sea,  not  one  was  known  to 
have  contracted  influenza  at  sea,  and  also  showed  that  epi- 
demics occurred  on  board  vessels  only  after  communication 
with  another  vessel.  It  will  be  interesting  to  note  later  just 
how  the  disease  has  eff'ected  Europe,  if  at  all,  during  this 
epidemic  and  whether  the  great  decrease  in  amount  of  travel 
and  commencial  intercourse  has  had  any  effect.  It  has  oc- 
curred to  me,  from  what  meager  information  could  be  ob- 
tained, that  the  disease  and  its  complications  has  been  most 
severe  in  the  Northern  and  Lake  cities  and  the  two  coasts. 
Study  of  reliable  sources  of  information  will  interest  us  and 
we  may  determine  that  it  has  followed  the  main  arteries  of 
travel.  Isolation  is  difficult  in  the  mild  cases  because  of  the 
doubt  of  diagnosis.  It  has  been  my  practice  with  my  cases 
to  have  them  use  old  cloths  or  pieces  of  gauze  in  collecting 
the  secretions  of  the  nose  and  having  them  burned.  In 
sneezing  and  coughing,  the  patient  is  to  protect  the  face 
with  these  cloths.  I  have  also  been  in  habit  of  advising  mem- 
bers of  the  family,  in  contact  with  the  disease,  to  use  sprays 


212       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

into  the  nose  and  to  use  some  sort  of  an  antiseptic  mouth 
wash.    Isolation  of  the  most  severe  cases  is  recommended. 

Patient  should  be  placed  in  bed  as  soon  as  diagnosis  is 
made  and  put  upon  a  light  and  nutritious  diet  and  instructed 
to  dring  large  quantities  of  cold  drinks.  Ten  grains  of  Dov- 
er's powder  is  given  at  bedtime  on  the  first  day  of  attack; 
this  is  followed  up  by  broken  doses  of  calomel.  The  salicy- 
lates seem  to  be  the  drug  of  choice ;  I  usually  give  it  in  the 
following  combination:  Acid  acetylo-salic,  grains  5;  so- 
dium benzoate,  grains  2;  camphor  monobromate,  grains  2, 
in  capsule  every  two  hours.  I  have  no  faith  in  the  use  of 
quinine  in  these  cases.  It  seems  to  increase  the  nervousness 
of  the  patient  and  adds  to  the  discomfort  of  the  headache 
and  sleeplessness.  If  the  sleeplessness  demands  attention, 
I  usually  give  some  hypnotic,  as  sulfonal.  For  the  coryza  I 
usually  use  in  the  nose  frequent  applications  of  lO  to  20  per 
cent  solution  of  argyrol;  following  this  I  usually  spray  the 
nares  with  some  antiseptic  solution,  such  as  Dobell's  solu- 
tion or  liquor  antisepticus  compound  alkaline ;  better  still,  a 
spray  of  some  oily  solution.  I  usually  use  albolene  spray 
solution.  Steam  inhalations  of  tincture  of  benzoin  com- 
pound are  serviceable.  The  most  difficult  symptoms  to  con- 
trol is  the  distressing  cough  and  I  have  found  nothing  that 
relieved  this  condition  to  any  extent,  although  I  frequently 
use  the  following:  Ammon.  muriate,  gr.  10;  potass,  iodide, 
grs.  3 ;  fl.  ext.  glycerrh,.  min.  10 ;  syrup  of  prunus  virgin,  q.s., 
drs.  1,  every  two  or  three  hours.  If  the  cough  still  was  very 
distressing,  one-eight  of  a  grain  of  codeine  phosphate  was 
added.  The  most  serviceable  drug  that  I  have  found,  per- 
haps, was  the  creosote  carbonate.  The  temperature,  when 
it  was  present  to  any  degree,  was  controlled  in  the  usual 
way.  The  profuse  sweating,  when  present,  was  usually  eas- 
ily controlled,  when  necessary,  by  small  doses  of  atropine. 
The  vaccines  I  have  found  of  little  use.  I  believe  this  is 
generally  accepted  to  be  the  fact. 

It  is  well  here  to  voice  a  protest  against  the  promiscuous 
use  of  stock  vaccines.    I  heartily  disapprove  of  using  a  gun- 


SELECTED   ARTICLES  213 

shot  vaccine  containing  the  products  of  from  four  to  eight 
different  kinds  of  bacteria  in  cases  diagnosticated  from 
symptoms  alone.  It  seems  foolhardy  to  me  to  follow  this 
practice  unless  we  have  a  definite  bacteriological  diagnosis. 
If  I  had  a  severe  case  of  pneumonia  without  a  definite  and 
sure  bacteriological  diagnosis  I  would  certainly  hesitate  to 
have  the  patient  go  through  even  a  mild  negative  phase  un- 
less I  was  certain  that  the  end  results  would  effect  the  in- 
fecting micro-organism.  Such  practice  is  not  only  not  good 
practice  but  is  certainly  unscientific. 

Respiratory  Type — This  type  is  treated  as  in  the  ordinary 
type,  except  that  when  the  bronchial  symptoms  are  very 
severe  and  there  is  considerable  congestion,  some  counter- 
irritation  to  the  chest  is  serviceable.  The  one  I  find  most 
useful,  being  in  the  form  of  a  mustard  plaster.  Of  course 
if  pneumonia  complicates  the  trouble,  it  should  be  treated 
as  ordinary  pneumonia. 

Gastro-intestinal  Type — This  form  also  resists  treatment 
to  a  degree  as  in  the  other  forms,  small  broken  doses  of  calo- 
m.el  are  given,  patient  placed  upon  a  liquid  diet  and  encour- 
aged to  drink  large  quantities  of  water.  Champagne  in 
small  amounts  will  frequently  take  care  of  the  vomiting.  An- 
other preparation  that  I  have  found  useful  in  these  cases,  is 
the  bile  salts  combined  with  pepsin  and  pancreatin. 

If  circulatory  symptoms  arise,  the  patient  is  kept  abso- 
lutely quiet  in  bed  and  strychnine,  one-fiftieth  grain  doses, 
given  three  times  a  day. 

Convalescence — The  convalescence  gives  the  attending 
physician  his  greatest  worry,  as  it  is  usually  long  compared 
with  the  severity  of  the  disease.  And  because  of  the  great 
debility  and  prostration,  the  patient  complains  so  often  that 
he  does  not  recover  as  quickly  as  he  thinks  he  should.  He 
can  not  understand  why  this  should  be.  And  while  he  may 
not  be  confined  to  his  bed,  he  should  be  confined  to  his  home 
and  warmly  clothed  but  in  a  room  well  ventilated.  Good 
nourishing  diet  with  some  supportive  treatment  should  be 


214       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

given  until  patient  feels  quite  himself  again.    A  strychnine 
tonic  in  these  cases  is  never  amiss. 

Since  this  paper  was  written,  Mathers,  of  Chicago,  has 
made  some  valuable  bacteriological  findings  in  regards  to 
our  present  epidemic.  He  has  found  a  hemolytic  streptococ- 
cus in  the  secretions  of  the  nose,  the  pharynx  and  bronchi. 
But  I  believe  we  must  make  further  search  before  we  can 
accept  conclusively  bacteriological  findings  of  these  secre- 
tions. From  what  has  been  quoted  above,  influenza  is  a  gen- 
eral systemic  infection  and  blood  cultures  and  cultures  taken 
at  post-mortem  will  determine  the  true  etiology.  During 
any  systemic  infection,  no  matter  what  its  nature,  we  have 
increased  numbers  of  all  sorts  of  bacteria  in  the  above  secre- 
tions. For  instance  in  any  sputum  examination  of  an  ad- 
vanced tuberculous  condition  we  find  streptococci  and 
staphylococci  and  even  influenza  w^hich  often  predominate. 
Yet  from  our  symptoms  of  the  disease  and  the  extreme  pros- 
tration following  it,  Mathers'  findings  seem  to  be  of  a  great 
deal  of  importance  to  us. — The  Medical  Herald. 


EXTRACTS  FROM  JOURNALS  215 


ExtrartB  tram  ^Qmt  anJi  SsimQn  Snurttalfl 


SURGICAL 


Operation  for  Aneurysms  of  Extremity. 


The  patient  whose  case  is  cited  by  Bernheim  had  an  an- 
eurysm of  the  right  popliteal  artery,  of  one  month's  dura- 
tion, but  which  was  increasing  in  size  somewhat  rapidly. 
At  the  operation  a  spindle-shaped  tumor  presented  and  was 
opened  on  its  dorsal  aspect,  revealing  only  two  openings,  the 
entrance  and  exit  of  the  popliteal  artery,  the  two  points  be- 
ing distant  about  an  inch  and  a  half  from  one  another,  and 
only  the  faintest  sign  of  a  groove  being  apparent  between 
them.  The  popliteal  vein  was  so  densely  adherent  to  the  sac 
that  it  was  impossible  to  separate  it  without  taking  part  of 
the  sac  wall,  which  was  done.  A  reconstructive  Matas  endo- 
aneurysmorraphy  was  impossible,  hence  Bernheim  removed 
about  15  cm.  of  the  internal  saphenous  vein  from  the  affected 
leg  at  the  knee  and,  after  proper  preparation,  interpolated 
about  15  cm.  of  it  between  the  severed  ends  of  the  popliteal 
artery.  Only  the  ends  of  the  sac  were  cut  away,  the  remain- 
der being  left  to  be  folded  around  the  transplant  as  a  partial 
reinforcement.  Carrel's  end-to-end  suture  was  used.  At 
the  conclusion  of  the  suturing  blood  went  through  the  graft 
in  a  normal  manner.  An  uninterrupted  convalescence  en- 
sued. All  pain  and  discomfort  in  the  leg  disappeared  and  a 
curious  operative  "dead  feeling"  of  the  great  toe  had  given 
way  to  a  normal  feeling.  Pulsation  could  be  felt  all  along 
the  vein  graft  as  well  as  in  the  arteries  of  the  foot. — The 
Journal  of  the  Amer.  Med.  Asso. 


Thread  Drainage. 


Chaput   expatiates  on   the  advantages    of  one    or    more 
threads,  silk  fibers,  wires  or  rubber  pencils  from  3  to  7  mm. 


216        NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

in  diameter  to  drain  wounds,  abscesses  and  fistulas.  He  in- 
sists that  the  drainage  is  always  good  because  the  thread 
passes  through  openings  very  large  in  comparison  to  its 
diameter ;  there  is  no  dead  space,  and  the  lips  of  the  wound 
fit  around  the  thread  drain  like  a  valve,  preventing  ingress 
of  air.  Abscesses  and  other  lesions  heal  more  rapidly  than 
with  tube  drains;  leave  no  traces.  The  abscess  can  be  punc- 
tured at  several  points  and  a  small  silk  thread  introduced 
at  each,  thus  facilitating  with  the  least  disfigurement.  He 
reviews  his  extensive  experiences  with  this  filiform  drain- 
age, as  he  calls  it,  in  abscesses  of  the  breast  and  anus,  ten- 
don-sheath phlegmons,  suppurating  wounds  of  the  knees  or 
other  joints,  in  peritonitis,  in  tuberculous  bone  and  joint  af- 
fections, and  after  hysterectomy  and  other  operations.  A 
number  of  minor  technical  points  are  mentioned  for  each 
of  these  applications.  Among  the  advantages  extolled  are 
that  the  filiform  drains  leave  no  scar,  protect  against  slough- 
ing of  tissues,  are  not  so  painful  as  drain  tubes,  avert  com- 
plications, and  protect  against  infection  from  without.  They 
heal  up  a  purulent  pleurisy  in  a  few  days,  without  leaving  a 
fistula  or  requiring  resection  of  ribs.  They  do  not  keep  the 
wound  discharging,  like  tube  drains,  and  he  found  that  all 
wounds  and  cavities,  aseptic  or  infected  or  tuberculous, 
healed  up  remarkably  fast,  as  a  rule  in  from  ten  to  fifteen 
days. — The  Journal  of  the  Am.  Med.  Asso. 


A  Slmple  Method  of  Removing  Flat  Foreign  Bodies  from 
THE  Trachea  of  the  Young  Child. 


The  method  to  be  described  is  designed  for  the  rapid  re- 
moval of  flat  foreign  bodies  from  the  trachea  of  infants  and 
children  up  to  the  age  of  three  years.  To  the  beginner  no 
operation  is  more  difficult  than  the  removal  of  foreign  bod- 
ies through  the  small  bronchoscopes  designed  for  infants. 
To  the  expert  the  operation  is  sometimes  fraught  with  diffi- 
culty, because  it  is  not  easy  to  work  through  a  4  mm.  tube 
unless  the  child  is  asleep,  which  adds  to  the  danger  of  trach- 


EXTRACTS  FROM  JOURNALS  217 

eoscopy.  Flat  foreign  bodies,  such  as  watermelon  seed,  sel- 
dom pass  into  the  bronchus  of  an  infant  or  young  child. 
They  lodge  in  the  trachea  almost  invariably,  and  necessitate 
a  tracheoscopy  for  removal.  To  obviate  the  difficulties  of 
working  through  a  small  tube,  I  had  a  small  Jackson  separ- 
able speculum,  made  which  measures  9.5  cm.  in  length  and 
10  mm.  in  diameter,  with  the  light  1  cm,  from  the  end  of  the 
tube.  With  the  handle  detached  the  speculum  is  passed  into 
the  throat,  with  the  child's  head  straight  on  the  table.  The 
epiglottis  is  pulled  up,  and,  with  the  child  breathing,  the 
trachea  can  be  explored  to  the  bifurcation.  A  foreign  body 
can  be  easily  seen,  and  if  it  is  light  in  weight,  as  a  water- 
melon seed,  it  moves  up  and  down  with  expiration  and  inspir- 
ation. Forceps,  introduced  between  the  vocal  cords,  are 
made  to  grasp  the  object,  which  is  quickly  removed.  No 
anesthetic  is  used.  Atropin  is  given  to  dry  up  secretions. 
In  the  removal  of  two  watermelon  seeds  from  the  trachea  of 
yound  children  I  was  surprised  at  the  excellent  view  of  the 
entire  trachea  with  the  head  straight  on  the  table.  I  have 
no  doubt  that  this  method  will  work  equally  as  well  with 
foreign  bodies  of  other  shapes.  Thus  far  I  have  had  occa- 
sion to  use  it  only  with  flat  foreign  bodies. — Maryland  Med- 
ical Journal. 


Intravenous  Injections  of  Chloral  in  the  Treat- 
ment OF  Tetanus. 


M.  Roch  and  Mile.  E.  Cottin  (Gazette  Medical  de  Paris) 
report  the  case  of  a  boy  aged  13  years  in  whom  this  method 
of  treatment  was  successfully  employed,  in  addition  to  the 
administration  of  chloral  by  the  mouth  and  by  the  rectum. 
The  patient  weighed  23  kilograms  and  in  the  course  of  20 
days  received  156  grams  of  chloral,  of  which  7  were  admin- 
istered by  the  mouth,  112  in  suppositories  or  in  enemata, 
and  37  in  intravenous  injections.  The  effect  of  this  method 
of  treatment  was  a  remarkable  control  of  all  the  spasmodic 
phenomena.     As  regards  the  proper  solutions  of  chloral 


218        NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

when  these  are  given  intravenously,  the  author  states  that 
they  should  not  be  of  greater  concentration  than  5  per  cent, 
and  should  be  allowed  to  flow  into  the  veins  very  slowly.— 
Medical  Progress. 


MBDICAL. 


Chenopodium  in  the  Treatment  of  Uncinariasis. 


In  the  Journal  of  the  American  Medical  Association  of 
November  6,  1915,  Bishop  and  Brosius  reach  these  conclu- 
sions : 

1.  The  method  of  administration  of  chenopodium  is  sim- 
ple, and  is  attended  with  less  inconvenience  and  discomfort 
than  is  thymol.  This  would  give  the  drug  an  important 
place  in  the  field  work  in  uncinariasis. 

2.  Chenopodium  can  be  given  at  shorter  intervals  than 
can  thymol,  and  a  cure  can  thereby  be  more  quickly  estab- 
lished, which  gives  it  a  greater  economic  value. 

3.  Chenopodium  is  non-toxic  m  therapeutic  doses. 

4.  Chenopodium  is  a  more  efficient  vermifuge  than  thymol 
in  the  treatment  of  uncinariasis. — The  Therapeutic  Gazette. 


Copper  Sulphate  Treatment  of  Trachoma. 


Prince's  copper  sulphate  treatment  of  trachoma  and  allied 
conditions  is  carried  out  as  follows : 

A  10  per  cent  solution  of  copper  sulphate  in  glycerin  is 
used  as  a  mother  liquor.  From  this  the  patient  is  directed 
to  make  an  aqueous  solution  daily  by  adding  one  drop  of  the 
mother  liquor  to  nineteen  drops  of  water.  This  1 :200  cop- 
per sulphate  solution  is  instilled  into  the  eye,  three,  four,  or 
even  six  times  a  day.  If  it  causes  too  much  reaction,  it  is 
further  diluted.  On  the  other  hand,  as  the  eye  gets  accus- 
tomed to  it,  the  solution  is  made  more  and  more  concentrated 
Prince,  however,  states  that  some  of  his  patients  used  a  so- 
lution of  1 :  50  or  even  stronger.    The  aqueous  solution  does 


EXTRACTS  FROM  JOURNALS  219 

not  seem  to  keep  well,  and  hence  should  be  made  up  fresh 
every  day. 

This  treatment  was  first  devised  by  Prince,  of  Spring- 
field, 111.,  who  found  it  to  work  well  in  trachoma  and  its 
complications  (corneal  ulcers  and  pannus).  He  also  used 
the  undiluted  10  per  cent  glycerin  solution  as  an  application 
after  expression  in  trachoma.  The  diluted  glycerin  in  Dr. 
Alexander  Duane's  hands  has  given  excellent  results  in  non- 
trachomatous  follicular  conditions. — Critic  and  Guide. 


Magnesium  Sulphate  in  Non-Amebic  Dysentery. 


Dr.  F.  Wyatt-Smith  (British  Medical  Journal,  November 
27,  1915),  has  this  to  say:  In  February,  1898,  when  our 
forces  engaged  against  the  Waziris  on  the  northwest  fron- 
tier of  India  were  being  exhausted  by  dysentery,  you  were 
good  enough  to  publish  my  experience  in  South  America  in 
the  treatment  of  non-amebic  dysentery  by  dram  doses  of 
magnesium  sulphate  every  two  hours.  I  found  it  to  be  a 
specific;  and  the  observation  was  confirmed  by  correspond- 
ents at  the  front,  by  the  medical  officer  in  charge  of  the  goal 
at  Mauritius,  and  later  in  the  South  African  war,  by  friends 
engaged  in  it.  The  observation  is  not  new,  for  a  correspond- 
ent in  Belfast  pointed  out  that  it  was  published  at  least  three 
hundred  years  ago. — Critic  and  Guide. 


Moblilzation  of  the  Lung  in  Treatment  of  Pulmonary 
Tuberculosis  in  Early  Stages. 


Kuhn  has  now  ten  years  of  experience  with  his  suction 
mask,  a  devise  worn  over  the  mouth  and  nose  which  by  val- 
vular action  impedes  inspiration  while  permitting  free  ex- 
piration. The  consequence  is  that  the  air  in  the  air  passa- 
ges becomes  rarefied,  the  muscles  of  chest  and  neck  work 
harder,  and  the  upper  part  of  the  chest  is  mobilized  as  under 
no  other  conditions.  He  says  that  his  mask  has  been  applied 
in  thousands  of  cases,  and  the  lungs  and  diaphragm  thus  ex- 


220       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

ercised  provide  better  conditions  for  recuperation  and  cure 
of  tuberculous  processes  than  any  other  means  can  offer. 
The  blood  and  lymph  flow  more  rapidly  and  abundantly 
through  parts  thus  being  exercised,  while  the  conditions 
with  the  suction  mask  prevent  any  tugging  on  the  tissues 
and  ward  off  all  tendency  to  hemorrhage.  The  lungs  can  be 
vigorously  exercised  in  this  way  in  cases  in  which  the  slight- 
est physical  exertion  otherwise  is  contraindicated. 

The  suction  mask  also  realizes  a  kind  of  autoinoculation 
therapy.  The  temperature  is  a  delicate  index  of  the  action 
of  toxins,  and  hence  the  record  of  the  temperature  is  the 
guide  as  to  the  practicability  of  the  suction  mask  in  the  in- 
dividual case.  By  mobilization  of  the  lung  in  this  way,  the 
blood  and  lymph  sweat  through  it  and  wash  out  bacterial 
products  into  the  general  circulation,  thus  realizing  what 
amounts  actually  to  a  course  of  tuberculin  treatment,  with 
resulting  production  of  antibodies.  When  the  slight  rise  in 
temperature  shows  that  toxins  are  being  swept  into  the  gen- 
eral circulation,  he  then  gives  the  organism  a  chance  for 
complete  rest  while  the  production  of  antibodies  is  going  on. 
His  mask  thus  aims  to  accomplish  the  exact  reverse  of  the 
induced  artificial  pneumothorax,  and  his  experience  with 
thousands  of  cases  has  demonstrated,  he  reiterates,  that  this 
mobilization  treatment  in  the  early  stages  is  the  most  prom- 
ising of  all  methods  of  treating  pulmonary  tuberculosis,  and 
that  some  contrivance  like  the  suction  mask  seems  to  be  the 
means  best  adapted  for  the  purpose. — The  Journal  of  the 
Amer.  Med.  Asso. 


OBSTETRICAL 


Painless  Childbirth. 


On  Wednesday,  March  1,  1916,  at  Carnegie  Hall,  was  held 
the  first  Birth  Control  mass  meeting.  The  oratory — as 
much  as  we  were  able  to  endure  of  it — was  a  fiasco,  but  the 
immense  audience,  which  filled  that  huge  hall  from  the  or- 


EXTRACTS  FROM  JOURNALS  221 

chestra  to  the  back  row  of  the  topmost  tier,  loudly  applaud- 
ing whenever  they  caught  a  bold  word  in  favor  of  birth  con- 
trol, was  eloquent  testimony  to  the  fact  that  at  last  the  peo  • 
pie  insist  on  knowing  the  ways  and  means  of  preventing 
conception. 

Not  long  ago,  the  profession  shook  its  dignified  head  when 
Twilight  Sleep  settled  over  the  land,  but  the  lay  agitation 
for  Dammerschlaf  plainly  showed  that  the  people  had  grown 
tired  of  biblical  curse  of  maternity  in  Genesis  III,  16,  "'I 
will  greatly  multiply  thy  sorrow,  thou  shalt  bring  forth  chil- 
dren,'— and  were  demanding  painless  childbirth.  Whether 
morphine-scopolamine  is  the  ideal  combination  matters  lit- 
tle, for  the  proper  drugs  can  be  found  later,  but  it  is  of  great 
social  significance  that  women  refuse  any  longer  to  bear 
children  in  agony — and  they  are  wholly  right.  After  many 
centuries  of  travail,  the  mothers  of  the  race  have  finally 
learnt  that  there  is  such  a  word  as  eutocia  in  the  medical 
dictionary. 

Carl  Henry  Davis,  associate  in  obstetrics  and  gynecology. 
Rush  Medical  College,  is  only  lukewarm  for  the  Frieburg 
method,  but  he  is  most  enthusiastic  for  nitrous  oxid-oxygen 
analgesia  in  labor,  and  has  written  a  little  volume  on  the 
subject,  which  has  recently  been  published  by  Forbes  and 
Co.,  of  Chicago.  About  twelve  years  ago  at  the  Presbyte- 
rian Hospital,  the  use  of  nitrous  oxid  and  oxygen  in  obstet- 
rical work  was  begun  by  Dr.  Davis'  chief,  J.  Clarence  Web- 
ster, and  the  present  production  voices  their  ideas  and  re- 
counts their  results. 

"It  is  the  right  of  woman,"  says  Dr.  Davis,  "to  demand 
relief  from  the  pains  of  childbirth,  and  it  is  the  duty  of  the 
physician  to  relieve  her  of  these  pains  in  the  same  spirit  that 
he  relieves  other  suff'ering.  The  pain  of  labor  causes  shock, 
and  is,  I  believe,  more  dangerous  than  the  proper  use  of  any 
of  the  analgesics  now  employed.  According  to  the  author, 
the  analgesic  of  choice  is  nitrous  oxid-oxygen. — Medical  Re- 
vieiv  of  Revievjs. 


222     nashville  journal  of  meidicinb  and  surgery 
Cesarian  Section. 


In  1879,  Felkin,  an  African  traveler,  witnessed  a  cesarian 
section  performed  by  the  natives  in  the  heart  of  Uganda. 
The  woman  was  held  in  a  reclining  posture  by  two  men.  At 
her  side  was  a  gourd  of  banana  wine,  and  she  was  half  drunk 
The  operator  stood  at  her  left.  First  he  washed  his  hands 
in  banana  wine,  then  he  washed  the  belly  with  the  same — 
active  antiseptic  measures.  With  a  short  curved  knife  he 
made  one  incision  through  the  belly,  right  into  the  uterus 
and  quickly  delivered  the  child  alive,  an  assistant  holding 
the  uterine  incision  open  by  hooking  his  fingers  into  it.  By 
uterine  massage,  the  placenta  was  expressed  and  hemor- 
rhage controlled.  Several  bleeding  points  were  cauterized 
with  a  hot  iron.  The  cervix  was  dilated  from  above  with 
the  fingers.  The  assistants  then  turned  the  patient  on  her 
side  to  allow  the  blood  to  drain  out  of  the  peritoneal  cavity, 
the  intestines  being  retained  by  a  square  of  plaited  twigs, 
after  which  the  belly  was  sewed  up  with  pins  and  figure-of- 
eight  sutures.  The  pins  were  made  from  bamboo  stick,  the 
sutures  from  reed  fibres.  The  wound  was  covered  with  a 
paste  made  of  aromatic  herbs.  The  patient  recovered  in  11 
days,  having  run  a  mild  febrile  course.  Without  doubt,  this 
operation  must  have  been  performed  for  many  centuries  for 
the  technique  to  be  so  perfectly  developed. — DeLee,  Illinois 
Medical  Journal. 


EDITORIAL  223 


lE&ttonal 


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The  Present  High  Standard  in  Medical 
Education. 


The  present  high  standard  in  medical  education  is  the  re- 
sult of  the  hard  work  of  a  relatively  small  number  of  physi- 
cians earnestly  interested  in  an  altruistic  work.  Not  only 
the  medical  profession  but  the  public  should  feel  deeply 
grateful  to  these  unselfish  men;  the  profession,  because  of 
the  higher  plane  it  will  attain,  the  public,  because  of  the 
better  service  it  will  get. 

But,  however  much  we  respect  those  men  and  admire  the 
results  of  their  efforts,  we  can  not  help  but  feel  that  the 
present  high  standard  is  far  from  an  absolute  good. 

We  hope  there  are  some  very  weak  links  in  our  chain  of 
reasoning,  but  all  evidence  at  hand  points  to  the  fact  that 
the  future  dangers  to  be  mentioned  below  are,  or  rather  will 
be,  actual  and  not  fanciful.  In  making  these  observations 
we  do  not  wish  to  be  classed  with  those  who  think  there  is 
danger  of  the  physician  becoming  "overeducated."  No  such 
danger  ever  did  or  ever  will  exist,  though  there  is  some  dan- 
ger of  the  education  running  too  deep  in  wrong  channels. 

It  is  not  the  danger  of  overeducation  that  threatens  but 
rather  the  danger  of  undersupply  of  the  educated  product — 
a  lack  of  physicians ;  and  the  evil  effects  of  this  as  we  see 
them  are  as  follows : 


224        NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

1.  A  medical  aristocracy. 

2.  A  scarcity  of  physicians  in  rural  communities. 

3.  More  extensive  use  of  patent  medicines. 

4.  A  great  increase  of  irregulars. 
Taking  these  headings  seriatim : 

1.  The  study  of  medicine  will  be  impossible  for  many.  The 
higher  preliminary  education,  the  longer  time  in  the  medical 
school,  and  the  final  hospital  work  all  together  mean  6-10 
years  time,  and  those  dependent  on  others  can  hardly  expect 
the  most  generous  father  to  bear  the  burden  of  expense  un- 
less he  is  fairly  well  to  do.  Some  boys,  of  course,  will  work 
their  way  through  college,  but  the  number  must  necessarily 
be  relatively  small  in  this  day  and  time  when  there  are  so 
many  fields  of  activity  open  to  young  men. 

2.  Men  will  not  spend  so  much  time  and  do  such  hard  work 
in  order  to  prepare  themselves  to  practice  in  rural  communi- 
ties. Furthermore,  the  man  raised  in  luxury  and  affluence 
will  seldom  voluntarily  give  up  that  mode  of  life  for  the  hard 
life  of  a  country  doctor.  Our  future  graduate  will  head  for 
the  city,  and  his  aim  will,  of  course,  be  some  specialty.  Since 
many  will  go  to  cities  the  competition  will  be  great.  This  will 
drive  some  to  the  smaller  towns,  but  hardly  to  communi- 
ties of  200-500  people.  This  simply  means  such  small  com- 
munities will  suffer  for  want  of  doctors.  Wherever  there  is 
one  physician,  there  should  be  at  least  two,  since  otherwise 
there  is  no  com.petition  and  the  people  are  the  sufferers.  In 
the  near  future,  however,  small  communities  will  be  glad  to 
have  anything  looking  like  a  doctor. 

3.  If  physicians  are  scarce,  the  use  and  abuse  of  patent 
medicines  will  become  even  greater  than  at  present.  This 
is  so  evident  that  it  would  not  be  surprising  to  find  patent 
medicine  manufacturers  the  strongest  advocates  of  the  high 
standard  in  medical  education. 

4.  If  irregulars  flourish  and  get  rich  in  our  cities  where 
many  worthy  young  doctors  are  almost  starving,  what  m.ust 
be  expected  later  in  small  communities  where  there  will  be 
no  doctors.    To  answer  this  is  unnecessary  because  you  have 


EDITORIAL  225 

already  pictured  in  your  mind's  eye  the  swallow-tailed  fake 
plying  his  trade  and  collecting  his  fortune. 

(The  above  are  some  of  the  dangers  as  we  see  them.  They 
may  not  be  real,  they  may  be  the  product  of  imagination, 
but  we  hardly  think  so.) 

Since  writing  the  above  we  have  read  an  article 
by  Gordon  Wilson— J.  A.  M.  A.,  April  8,  1916— 
in  which  he  points  to  a  future  undersupply  of  phy- 
sicians. To  avoid  this  he  suggests  two  types  of  medical 
school,  one  of  which  types  will  train  its  students  for  teach- 
ing, research  work,  sanitation,  etc.,  as  a  representative  of 
which  he  mentions  Johns  Hopkins,  the  other  type,  repre- 
sented by  the  average  first  class  school  of  today,  will  train 
its  students  for  actual  practice.  We  hardly  think  this  plan 
feasible,  except  insofar  as  every  medical  school  should  offer 
special  lecture  courses  for  students  intending  to  take  up 
teaching,  research  work,  etc.  No  medical  school  should  be 
allowed  to  lose  sight  of  the  ultimate  aim  of  all  medical  edu- 
cation— the  prevention  and  cure  of  disease.  And  in  order 
that  no  such  weakness  may  develop  among  our  full-time  pro- 
fessors— we  have  seen  evidences  of  this  very  weakness — the 
regular  course  of  study,  hospital  work  and  several  years  of 
practice,  should  be  the  sine  qua  non  of  a  full  time  professor- 
ship of  any  subject. 

In  this  same  article  he  shows  how  the  freshman  enroll- 
ment of  students  in  the  Baltimore  schools,  aside  from  Johns 
Hopkins,  has  decreased  from  265  in  1905  to  44  in  1915. 
(Here  in  Nashville  there  has  been  a  similar  decrease,  the 
1915  freshman  enrollment  being  about  30,  while  in  1905 
the  enrollment  was  at  least  180.)  He  furthermore  shows  in 
two  tables,  as  an  actual  fact,  the  danger  we  mentioned  under 
caption  (2),  comparing  Johns  Hopkins  with  the  other  Bal- 
timore schools  his  tables  show  that  graduates  from  the 
former  seldom  locate  in  rural  communities. 

The  questions  we  would  raise  are:  1.  how  will  our  rural 
districts  fare  with  few  or  no  physicians  and  weak,  inefficient 
laws  against  quacks  and  quack  medicines,  and  (2),  will  the 


226       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

advocates  of  the  high  standard  be  satisfied  for  the  present 
until  we  know  more  definitely  the  remote  effects,  or  will  they 
continue  to  raise  the  standard  regardless  of  the  public  wel- 
fare?—W.  T.  B. 


The  Galloway  Memorial  Hospital. 

The  recent  campaign  in  Nashville  to  raise  $200,000  in  ten 
days  for  the  completion  of  the  Galloway  Memorial  Hospital, 
was  a  grand  success  in  every  respect.  Not  only  was  the  re- 
quired amount  pledged,  but  $70,000  in  addition.  There  were 
more  than  500  men  and  women  working  hard  to  raise  the 
necessary  amount  and  while  in  the  mid-part  of  the  campaign 
the  outcome  seemed  dubious  to  some,  never  once  did  the 
general  enthusiasm  waver.  While  the  work  of  all  interested 
was  commendable,  that  of  the  Vanderbilt  student  body  and 
the  local  nurses,  both  those  in  training  and  the  graduates,  de- 
serves special  mention.  The  large  gift  of  $20,000  by  Miss 
Johnson,  of  Gallatin,  and  $60,000  by  Mr.  J.  P.  Moore  of 
Franklin,  as  well  as  the  $12,000  donated  by  the  N.,  C.  &  St. 
L.  Railroad,  played  a  large  part  in  the  final  outcome. 

The  unit  of  the  hospital  for  the  completion  of  which  this 
sum  was  subscribed  should  be  rushed  on  to  completion,  not 
only  because  Nashville  is  in  sore  need  of  more  hospital  space, 
but  also  in  order  that  the  Vanderbilt  medical  students,  who 
have  worked  so  hard  for  the  hospital,  may  get  the  benefit  of 
the  better  teaching  facilities  this  institution  will  offer. 

With  this  hospital  and  the  miillion-dollar  endowment  ac- 
quired a  few  years  ago,  the  Vanderbilt  Medical  School  should 
soon  stand  forth  as  a  power  in  the  medical  education  of  the 
United  States.~W.  T.  B. 


Extra  Copies. 


Many  physicians  will  receive  sample  copies  of  the  Nash- 
ville Journal  of  Medicine  and  Surgery  and  be  asked  to 
subscribe    to    this    old,    sterling    publication.     We    offer 


EDITORIAL  227 

as  premiums  to  new  subscribers  a  handsome  certified  clini- 
cal thermometer  in  case  with  chain  and  a  ten-weeks  trial 
subscription  to  Harper's  Weekly,  a  publication  that  pre- 
sents war  pictures  and  war  news  of  the  greatest  interest  to 
everyone  fortunate  enough  to  obtain  copies.  The  Journal 
for  one  year,  Harper's  Weekly  for  ten  weeks,  and  a  reliable 
clinical  thermometer,  all  for  $1.45.  We  trust  our  readers 
will  appreciate  the  advantages  we  offer  and  send  in  their 
names  as  subscribers.  The  Journal  is  essentially  an  inde- 
pendent, non-partisan  publication,  devoted  to  the  needs  of 
the  general  practitioner  and  open  always  to  communications 
for  the  benefit  of  the  medical  profession.  Let  us  have  your 
subscription  without  delay. 


Officers  of  Tennessee  State  Medical  Association. 


The  officers  elected  for  the  ensuing  year  were :  Dr.  C.  N. 
Cowden,  of  Nashville,  president;  vice  presidents,  Dr.  C.  J. 
Carmichael,  Knoxville;  Dr.  J.  T.  Moore,  Algood;  Dr.  J.  L. 
McGehee,  Memphis ;  secretary.  Dr.  Olin  West,  to  succeed  Dr. 
Cowden  as  member  of  the  board  of  trustees,  and  treasurer, 
Dr.  J.  A.  Gallogher ;  the  two  latter  of  Nashville. 


Preliminary  Program  American  Proctologic  Society. 

Eighteenth  Annual  Meeting,  Detroit,  Mich., 

June  12  and  13,  1916. 


Headquarters  and  Place  of  Meeting,  Hotel  Slater. 
The  Profession  is  Cordially  Invited  to  Attend  All  Meetings. 


Executive  board  meets  at  11  a.  m. 

First  regular  session  at  2  p.  m. 

Annual  Address  of  the  President — Subject:  Why  Proc- 
tology has  been  made  a  Specialty.  T.  Chittenden  Hill,  Bos- 
ton Mass. 

PAPERS. 

1 — A  Review  of  Proctologic  Literature  for  1915.     Samuel 
T.  Earle,  Baltimore,  Md. 


228       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

2 — Post-Operative  Treatment  in  Rectal  Surgery.    Wm.  H. 

Stauffer,  St.  Louis,  Mo. 
3 — Auto-rectal  Injuries.    Samuel  G.  Gant,  New  York  City, 

N.  Y. 
4 — Some  Observations  on  Hernia  in  Relation  to  Intestinal 

Stasis.    Wm.  M.  Beach,  Pittsburg,  Pa. 
5 — Intestinal  Symptoms  due  to  Achylia  Gastrica.    Alois  B. 

Graham,  Indianapolis,  Ind. 
6 — Non-Specific  Ulceration  of  the  Rectum  and  Anus,  with 
Report  of  a  Case  of  Anal  Herpes  Zoster.    Lewis  H. 
Adler,  Jr.,  Philadelphia,  Pa. 
7 — Malignant  Transformation  of  Benign  Growths.    Frank 

C.  Yeomans,  New  York  City,  N.  Y. 
8 — Acute  Angulation  and  Flexure  of  Sigmoid  as  a  Causa- 
tive Factor  in  Epilepsy;  Report  of  nine  new  Cases 
with  four  Recoveries.     Wm.  H.  Axtell,  Bellingham, 
Wash. 

9 — The  Vaccine  Treatment  of  Pruritus  Ani.    W.  H.  Kiger,       f  i 
Los  Angeles,  Cal. 
10 — Report  of  Experience  with  the  Vaccine  Treatment  of 

Pruritus  Ani.    Louis  J.  Hirschman,  Detroit,  Mich. 
11 — Posture  as  an  Etiologic  Factor  in  Splanchnoptosis.  Rol- 

la  Camden,  Parkersburg,  W.  Va. 

12 — Photography  for  Record  and  Teaching;  Lantern  Slide 

Demonstrations.    Collier  F.  Martin,  Philadelphia,  Pa. 

13 — The  Present  Status  of  Operations  for  Carcinoma  of  the 

Rectum  and  Lower  Third  of  the  Sigmoid.    Samuel  T. 

Earle,  Baltimore,  Md. 

14 — Observations  on  Fissure  of  the  Anus.    Rollin  H.  Barnes, 

St.  Louis,  Mo. 
15 — The  Treatment  of  Hemorrhoids  by  a  New  Method.    E. 

H.  Terrell,  Richmond,  Va. 
16— The  Relation  of  Colonic  Disease  to  the  Kinetic  System. 

James  A.  MacMillan,  Detroit,  Mich. 
17— The  Consideration  of  Rectal  and  Colonic  Disease  in  Life 
Insurance  Examinations.    Alfred  J.  Zoebel,  San  Fran- 
cisco, Cal. 


EDITORIAL  229 

18 — Spasmodic  Stricture  of  the  Rectum.  Louis  J.  Krouse, 
Cincinnati,  Ohio. 

19 — Some  Important  Pathological  Conditions  found  About 
the  Rectal  Outlet.  Lantern  Slide  Demonstration. 
Granville  S.  Hanes,  Louisville,  Ky. 

20 — The  Relation  of  the  Roentgenologist  to  the  Proctologist. 
Walter  L  Le  Fevre,  Cleveland,  Ohio. 

21 — Syphilis  of  the  Rectum.  G.  Milton  Linthicum,  Balti- 
more, Md. 

22 — Position  for  Sigmoidoscopic  Work.  Donly  C.  Hawley, 
Berlington,  Vt. 

23 — Sixth  Report  on  the  Treatment  of  Pruritus  Ani  by  Au- 
togenous Vaccines.  Dwight  H.  Murray,  Syracuse, 
N.  Y. 

24 — Gangrenous  Hemorrhoids;  Reports  of  Cases.  John  L. 
Jelks,  Memphis,  Tenn. 


Typhoid  Fever  Reduced  in  Rural  Communities. 


Reduction  in  typhoid  fever  and  improvement  in  sanitary 
conditions  have  followed  the  intensive  investigations  of 
rural  communities  carried  on  by  the  United  States  Public 
Health  Service  in  co-operation  with  local  and  State  health 
officers,  according  to  the  annual  report  of  the  Surgeon  Gen- 
eral of  that  service.  During  the  past  fiscal  year  16,369  rural 
homes  in  eight  different  states  were  visited  and  many  of 
them  revisited.  In  each  of  these  homes  information  was 
obtained  as  to  the  prevalence  of  disease  and  insanitary  con- 
ditions and  a  complete  sanitary  survey  of  the  premises  con- 
ducted. This  was  followed  by  reinspections  to  determine  if 
remedial  measures  had  been  instituted.  In  but  a  relatively 
small  percentage  of  the  cases  did  the  persons  concerned, 
after  having  their  attention  drawn  to  the  danger  of  a  par- 
ticular unhygienic  condition,  fail  to  inaugurate  corrective 
measures.  Stimulus  was  given  to  work  by  means  of  public 
lectures,  the  formation  of  active  sanitary  organizations,  and 
the  enlisting  of  all  public-spirited  citizens  in  the  campaigns 


230        NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

for  reform.-  Public  buildings  were  also  inspected  and  local 
authorities  given  expert  advice  in  solving  such  sanitary 
problems  as  the  disposal  of  excreta,  the  prevention  of  soil 
pollution,  and  the  maintenance  of  pure  water  supplies. 

The  surveys  made  during  the  year  1914  had  shown  that  in 
rural  communities  less  than  1  per  cent  of  the  homes  had  san- 
itary toilets,  and  that  more  than  50  per  cent  of  the  people 
were  using  water  from  polluted  sources.  This  condition, 
according  to  the  Public  Health  Service,  made  the  rural  sani- 
tation question  loom  large  among  the  matters  vitally  affect- 
ing the  welfare  of  the  nation.  Following  these  studies,  and 
as  a  result  of  the  interest  aroused,  the  typhoid  fever  rate, 
an  excellent  indicator  of  the  sanitary  status  of  a  community, 
has  in  some  places  frequently  been  cut  to  one-quarter  of  its 
previous  figure.  In  Berkeley  County,  West  Va.,  the  cases  of 
tyiDhoid  fever  were  reduced  from  429  to  40  in  one  year.  In 
Orange  County,  North  Carolina,  the  rural  sanitation  cam- 
paign resulted  in  a  reduction  of  the  cases  from  59  to  17. 

The  tangible  results  of  operations  in  rural  sanitation  in- 
dicate that  marked  advancement  in  maintaining  hygienic 
and  satisfactory  surroundings  in  country  districts  is  possi- 
ble by  the  application  of  the  common  principles  of  preven- 
tive medicine.  Insanitary  conditions  exist  largely  because 
they  are  not  known  to  be  such.  Actual  demonstrations  of 
their  harmfulness,  together  with  definite  recommendations 
for  their  correction,  remain  one  of  the  most  gratifying  and 
successful  methods  for  instituting  reforms  and  has  been,  in 
the  experience  of  the  Public  Health  Service,  invariably  ac- 
companied by  definite  and  measurable  results. 


Examination  of  Candidates  for  Assistant  Surgeon. 


I'reasury  Department. 
United  States  Public  Health  Service. 


Washington,  April  1,  1916. 
Boards  will  be  convened  at  the  Bureau  of  Public  Health 
Service,  3  "B"  Street,  S.  E.,  Washington,  D.  C,  and  at  a 


EDITORIAL  231 

number  of  the  Marine  hospitals  of  the  Service,  on  Wednes- 
day, May  31,  1916,  at  10  o'clock  a.  m.,  for  the  purpose  of 
examining  for  admission  to  the  grade  of  Assistant  Surgeon 
in  the  Public  Health  Service. 

The  candidate  must  be  between  23  and  32  years  of  age,  a 
graduate  of  a  reputable  medical  college,  and  must  furnish 
testimonials  from  two  responsible  persons  as  to  his  profes- 
sional and  moral  character,  together  with  a  recent  photo- 
graph of  himself.  Credit  will  be  given  in  the  examination 
for  service  in  hospitals  for  the  insane,  experience  in  the  de- 
tection of  mental  disease,  and  in  any  other  particular  line 
of  professional  work.  Candidates  must  have  had  one  year's 
hospital  experience  or  two  years'  professional  work. 

Candidates  must  be  not  less  than  5  feet,  4  inches,  nor 
more  than  6  feet,  2  inches,  in  height,  with  relatively  corre- 
sponding weights. 

The  following  is  the  order  of  examination:  1,  Physical; 
2,  Oral;  3,  Written;  4,  Clinical. 

Candidates  are  required  to  certify  that  they  believe  them- 
selves free  from  any  ailment  which  would  disqualify  them 
for  service  in  any  climate. 

Exam-inations  are  chiefly  in  writing,  and  begin  with  a 
short  autobiography  of  the  candidate.  The  remainder  of 
the  written  exercise  covers  the  various  branches  of  medi- 
cine, surgery,  and  hygiene. 

The  oral  examination  includes  subjects  of  preliminary 
education,  history,  literature,  and  natural  sciences. 

The  clinical  examination  is  conducted  at  a  hospital. 

The  examination  usually  covers  a  period  of  about  ten  days. 

Successful  candidates  will  be  numbered  according  to  their 
attainments  on  examination,  and  will  be  commissioned  in 
the  same  order.    They  will  receive  early  appointments. 

After  four  years'  service,  assistant  surgeons  are  entitled 
to  examination  for  promotion  to  the  grade  of  passed  assist- 
ant surgeon.  Passed  Assistant  Surgeons,  after  12  years' 
service  are  entitled  to  examination  for  promotion  to  the 
grade  of  Surgeon. 


232       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Assistant  surgeons  receive  $2,000,  passed  assistant  sur- 
geons $2,400,  surgeons  $3,000,  senior  surgeons  $3,500,  and 
assistant  surgeon-generals  $4,000  a  year.  When  quarters 
are  not  provided,  commutation  at  the  rate  of  $30,  $40,  and 
$50  a  month,  according  to  the  grade,  is  allowed. 

All  grades  receive  longevity  pay,  10  per  cent  in  addition 
to  the  regular  salary  for  every  five  years  up  to  40  per  cent 
after  twenty  years'  service. 

The  tenure  of  office  is  permanent.  Officers  traveling  un- 
der orders  are  allowed  actual  expenses. 

For  invitation  to  appear  before  the  board  of  examiners, 
address  ''Surgeon-General,  Public  Health  Service,  Wash- 
ington, D.  C." 


Do  You  Know  That 


Sags  in  roof -gutters  may  act  as  mosquito  breeding  places  ? 

America's  most  valuable  crop  is  babies? 

The  public  cigar-cutter  is  a  health  menace? 

The  United  States  Public  Health  Service  maintains  a  loan 
library  of  stereopticon  slides? 

The  typhoid  rate  measures  accurately  community  intelli- 
gence ? 

Whooping  cough  annually  kills  over  10,000  Americans? 

Bad  housing  produces  bad  health? 

Rocky  Mountain  spotted  fever  is  spread  by  a  wood-tick? 


The  Samuel  D.  Gross  $1,500  Prize,  Philadelphia 
Academy  of  Surgery. 


(Essays  will  be  received  in  competition  for  the  prize  ur  ti/ 
January  1,  1920.) 

The  conditions  annexed  by  the  testator  are  that  the  prize 
"shall  be  awarded  every  five  years  to  the  writer  of  the  best 
original  essay,  not  exceeding  one  hundred  and  fifty  printed 
pages,  octavo,  in  length,  illustrative  of  some  subject  in  Sur- 
gical Pathology  or  Surgical  Practice,  founded  upon  original 


EDITORIAL  233 

investigations,  the  candidates  for  the  prize  to  be  American 
citizens." 

It  is  expressly  stipulated  that  the  competitor  who  receives 
the  prize  shall  publish  his  essay  in  book  form,  and  that  he 
shall  deposit  one  copy  of  the  work  in  the  Samuel  D.  Gross 
Library  of  the  Philadelphia  Academy  of  Surgery,  and  that 
on  the  title  page,  it  shall  be  stated  that  the  essay  was  award- 
ed the  Samuel  D.  Gross  Prize  of  the  Philadelphia  Academy 
of  Surgery. 

The  essays,  which  must  be  written  by  a  single  author  in 
the  English  language,  should  be  sent  to  the  "Trustees  of  the 
Samuel  D.  Gross  Prize  of  the  Philadelphia  Academy  of  Sur- 
gery, care  of  the  College  of  Phj^sicians,  19  S.  22d  St.,  Phila- 
delphia," on  or  before  January  1,  1920. 

Each  essay  must  be  typewritten,  distinguished  by  a  motto, 
and  accompanied  by  a  sealed  envelope  bearing  the  same 
motto,  containing  the  name  and  address  of  the  writer.  No 
envelope  will  be  opened  except  that  which  accompanies  the 
successful  essay. 

The  committee  will  return  the  unsuccessful  essays  if  re- 
claimed by  their  respective  writers,  or  their  agents,  within 
one  year. 

The  committee  reserves  the  right  to  make  no  award  if  the 
essays  submitted  are  not  considered  worthy  of  the  prize. 

William  J.  Taylor,  M.D., 
John  H.  Jopson,  M.D., 
Edward  B.  Hodge,  M.D., 

Philadelphia,  March  1,  1916.  Trustees. 


Pellagra  Prevention — Spring  Diet  Determines 
Summer  Symptoms. 


A  faulty  or  restricted  diet  at  this  season  of  the  year  is  the 
chief  factor  in  the  production  of  pellagra.  Measures  to  pre- 
vent the  development  of  the  disease  should  be  instituted 
during  the  early  spring  months,  according  to  a  circular  of 
information  issued  today  by  the  United  States  Public  Health 


234        NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Service.  While  the  manifestations  of  pellagra  are  in  most 
cases  not  in  evidence  until  June  or  July,  the  condition  invar- 
iably dates  from  a  faulty  diet  of  earlier  months.  Therefore, 
if  due  precautions  are  exercised  by  individuals  at  the  pres- 
ent time  the  havoc  wrought  by  this  scourge  may  be  greatly 
lessened,  if  not  entirely  eliminated. 

DANGER  SIGNALS. 

The  report  further  calls  attention  to  certain  danger  sig- 
nals which  should  be  recognized  by  those  who  reside  in  pel- 
lagrous districts  or  those  who  have  had  previous  attacks  of 
the  disease.  Among  such  warning  symptoms  are  extreme 
nervousness  or  change  in  the  mental  characteristics  of  the 
individual.  Weakness  or  debility,  a  disinclination  to  under- 
take the  ordinary  daily  tasks,  and  unexplained  digestive 
symptoms  may  all  be  premonitory  signs.  These  symptoms 
do  not,  of  course,  necessarily  mean  the  development  of  pel- 
lagra, but  taken  in  connection  with  the  history  of  a  one- 
sided, monotonous,  diet,  they  serve  as  a  definite  warning  of 
the  possibilities  of  its  onset. 

SPRING  DIET. 

The  diet  recommended  by  the  health  service  for  the  pre- 
vention of  pellagra  will  not  produce  results  if  followed  for  a 
week  or  ten  days  only,  but  if  continuously  and  consistently 
used,  under  circumstances  similar  to  its  administration  in 
the  various  institutions  where  the  experimental  tests  have 
been  performed,  it  will  protect  the  individual  against  the 
development  of  the  disease.  Necessarily,  a  rigid  unvaried 
diet  is  wholly  undesirable  and  the  menu  recommended  is 
only  to  indicate  in  a  general  way  the  character  of  the  food 
to  be  prescribed.  Frequently  the  element  of  poverty,  inac- 
cessibility to  market  supplies,  or  even  personal  idiosycrasy, 
may  require  some  modification  of  the  diet  table,  so  that  strict 
adherence  to  its  components  may  not  in  all  respects  be  prac- 
ticable. The  object  of  the  diet  as  submitted  is  to  minimize 
the  consumption  of  the  carbo-hydrate  (starchy  and  sweet) 
foods  and  to  increase  the  amount  of  fresh  animal  protein  and 
of  fresh  legumes  (peas  and  beans) . 


EDITORIALS  286 

The  breakfast,  for  example,  should  consist  of  oatmeal  and 
cream,  without  sugar,  with  either  ham  or  breakfast  bacon 
and  two  eggs.  Not  more  than  two  thin  slices  of  whole 
wheat  bread  should  be  taken,  preferably  untoasted.  Hot 
bread  or  biscuits  are  inadvisable.  A  glass  of  fresh  milk  is 
to  accompany  the  breakfast  and  either  oranges  or  grape 
fruit  may  be  the  initial  course.  The  dinner  should  consist 
of  either  pea  or  bean  soup,  prepared  from  dried  peas  or 
beans,  with  a  meat  stock.  The  meat  may  be  beef,  pork,  ham, 
chicken,  veal,  or  mutton,  prepared  in  whatever  manner  is 
the  most  appetizing,  preference  being  given  to  roasting  or 
broiling  rather  than  frying.  Hamburger  steak,  meat  hash, 
or  fish  may  be  substituted  to  afford  variety.  Care  should  be 
exercised  that  the  meats  are  not  overdone.  Of  vegetables, 
Irish  potatoes,  boiled  in  the  jacket  or  baked,  cabbage,  turnip 
or  mustard  greens,  collards  and  lettuce,  are  to  be  recom- 
mended. For  dessert,  stewed,  fresh  or  dried  fruit  will  prove 
sufficient.  The  dinner  should  be  acompanied  by  not  more 
than  two  thin  slices  of  whole  wheat  bread  and  a  glass  of 
buttermilk.  The  supper  should  consist  of  pork  and  beans, 
or  baked  beans  properly  seasoned,  the  usual  amount  of 
bread  and  a  glass  of  buttermilk.  If  preferred,  eggs,  scram- 
bled or  otherwise  prepared,  may  be  substituted  for  the  more 
substantial  ingredient  of  the  meal. 

DIET  CHEAP  AND  AMPLE. 

A  diet  such  as  the  above  is  not  prohibitive  as  to  cost,  at 
least  to  but  few  of  the  residents  of  the  country,  affords  a 
sufficient  number  of  heat  units,  if  taken  in  reasonable  quan- 
tity, and  will  effectually  prevent  the  development  of  a  dis- 
ease which  alone  caused  8,000  deaths  in  the  United  States 
during  the  past  year. 


Seventy-six  out  of  eighty-seven  cases  of  typhoid  fever 
which  occurred  in  a  recent  outbreak  have  been  traced  by  the 
United  States  Public  Health  Service  to  infected  milk.  Had 
the  first  cases  been  reported  to  a  trained  health  officer  the 
outbreak  could  have  been  stamped  out  promptly.  When 
will  we  learn  that  disease  prevention  is  sure  and  cheap  ? 


236        NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


lS^t\m\xtB  mh  look  Notir^a 


The  Practical  Medicine  Series,  Comprising  Ten  Volumes  on  the  Year's 
Progress  in  Medicine  and  Surgery,  Under  the  General  Editorial 
Charge  of  Charles  L.  Mix,  A.M.,  M.D.,  Professor  of  Physical  Diag- 
nosis in  the  Northwestern  University  Medical  School.  Vol.  1.  Gen- 
eral Medicine.  Edited  by  Frank  Billings,  M.S.,  M.D.,  Head  of  the 
Medical  Department  and  Dean  of  the  Faculty  of  Rush  Medical  Col- 
lege. Series  1916.  Chicago.  The  Year  Book  Publishers,  327  S.  La 
Salle  St. 

The  attention  of  our  readers  is  called  to  this  exceedingly 
useful  publication  consisting  of  a  series  of  ten  volumes  for 
the  year  issued  at  monthly  intervals  on  medicine  and  sur- 
gery. Each  volume  is  complete  on  the  subject  of  which  it 
treats,  so  that  the  physician  can  buy  only  the  parts  they 
desire.  This  volume  is  on  general  medicine  and  has  been  pre- 
pared by  the  well  known  Chicago  physician,  Dr.  Frank  Bil- 
lings. The  entire  subject  is  presented  in  astonishingly  small 
volume  and  is  complete  as  giving  the  reader  a  succinct  pre- 
sentation of  every  medical  subject,  all  of  which  is  brought 
fully  up-to-date,  presenting  the  latest  changes  and  advances 
in  the  science  and  practice  of  medicine.  As  a  reference  book 
it  is  unexcelled,  as  it  gives  a  quick  and  accurate  picture  of 
diseases,  their  recognition,  etiology,  pathology,  and  treat- 
ment. This  one  volume  is  worth  the  price  of  the  entire  set, 
and  the  other  numbers  to  be  issued  promise  to  be  equally  as 
good. 


PUBLISHERS'  DEPARTMENT  237 


Publtfilirr'fi  i^partm^ttt 


The  Remedy  of  Choice  in  Cardiac  Affections. 


It  is  interesting  to  note  the  growing  interest  medical  men 
are  taking  in  Cactina  Fillets  as  a  safe  and  dependable  car- 
diac tonic.  This  is  not  surprising;  indeed  the  only  surpris- 
ing feature  is  that  the  efficiency  of  this  remedy  has  not  been 
more  generally  realized.  Hardly  any  one  drug,  with  the 
possible  exception  of  digitalis,  has  a  broader  field  of  activity, 
and  there  are  many  competent  observers  who  place  it  first 
among  cardiac  remedies.  Experience  has  shown  that  the 
most  conspicuous  influence  of  Cactina  upon  the  heart  is  its 
effect  on  the  local  nutrition  and  consequent  increase  of  the 
muscular-motor  energy.  Certainly  it  is  the  heart  tonic  par 
excellence,  since  it  increases  heart  action  and  restores  nerve 
function  with  a  promptness  that  is  rarely  observed  with  any 
other  remedy. 

Made  from  a  dependable  preparation  of  Mexican  Cereus 
Grandiflorus,  Cactina  Fillets  are  especially  effective  in  func- 
tional disorders  of  the  heart  associated  with  feeble,  irregu- 
lar pulse,  more  or  less  dyspnea  and  a  sense  of  chest  oppres- 
sion. In  such  cases  the  effect  of  Cactina  Fillets  is  exceed- 
ingly gratifying,  the  heart  being  promptly  steadied  and 
strengthened,  and  dyspnea  markedly  relieved.  Tachycardia 
and  palpitation  are  quickly  controlled,  and  the  precordial 
sensations  which  cause  so  much  apprehension  are  soon  dis- 
pelled. 

In  accomplishing  the  foregoing,  the  physician  does  not 
have  to  apprehend  toxic  or  untoward  effects,  for  Cactina  Fil- 
lets are  not  only  non-cumulative  but  totally  devoid  of  all  un- 
pleasant or  disagreeable  action.  It  is  hardly  to  be  wondered 
at,  therefore,  that  careful,  painstaking  physicians  are  not 
only  using  Catina  Fillets  more  extensively  than  ever,  but  are 


238         NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

gradually  coming  to  look  upon  this  preparation  of  cactus  as 
the  remedy  of  choice  in  functional  affections  of  the  heart. 


Chemical  Food  is  a  mixture  of  phosphoric  acid  and  phos- 
phates, the  value  of  which  physicians  seem  to  have  lost  sight 
of  to  some  extent  in  the  past  few  years.  The  Robinson- 
Pettet  Co.,  incorporated,  to  whose  advertisement  in  this  is- 
sue we  refer  our  readers,  have  placed  upon  the  market  a 
much  improved  form  of  this  compound,  Robinson's  Phos- 
phoric Elixir.  Its  superiority  consists  in  its  uniform  com- 
position and  high  degree  of  palatability. 


Most  doctors  realize  that  as  a  symptom,  pain  has  as  a  rule 
considerable  diagnostic  significance.  Sometimes  at  least,  if 
not  often,  the  doctor  is  apt  to  overlook  one  fact,  viz.,  pain 
to  the  patient  is  a  condition  not  a  symptom — he  cares  less 
for  what  it  means  than  to  get  relief  from  it. 

Hence  the  doctor  is  sometimes  caught  upon  one  horn  of  a 
double  dilemma.  To  relieve  pain  by  ordinary  means — i.  e., 
hypodermatic  injection  or  narcotic,  given  per  os,  is  to  satisfy 
the  patient  but  mask  or  alter  the  meaning  of  certain  symp- 
toms. 

If  the  patient  is  left  to  suffer  while  the  case  is  studied,  the 
diagnosis  is  favored,  but  patient  and  friends  resent  what 
seems  to  them  to  be  neglect.  The  use  of  opium  or  similar 
drugs  to  relieve  pain  is  always  fraught  with  danger — it's 
almost  as  bad  as  trying  to  cut  off  a  dog's  tail  behind  his  ears ! 
Nature  has  provided  a  means  for  pain  relief  or  analgesia 
that  deserves  more  careful  and  general  use.  In  the  ar- 
rangement of  the  sympathetic  nervous  system,  the  spinal 
distributing  and  reflecting  centers,  lies  the  explanation  of 
the  good  effect  of  counter-irritation  and  analgesia  produced 
through  the  skin  hy  local  and  external  application. 

And  upon  such  natural  physiological  rules  and  working 
plans  is  based  the  action  of  the  Anodyne  "First-Aid,"  viz., 
K-Y  Analgesic. 


PUBLISHERS'  DEPARTMENT  239 

Being  greaseless  and  water-soluble,  K-Y  Analgesic  when 
applied  to  the  skin,  absorbs  rapidly,  penetrates  deeply,  re- 
lieves promptly  and  is  more  or  less  prolonged  in  action  and 
effect.  The  analgesic  agents  contained  in  it,  camphor,  men- 
thol, and  methyl  salicylate  are  active  but  non-irritant  or 
toxic,  so  that  K-Y  Analgesic  can  be  applied  as  often  as  nec- 
essary and  in  any  amount. 

It  does  not  stain  the  skin  or  soil  clothing. 

For  the  relief  of  headache,  neuralgia,  rheumatic  pains, 
stiff  and  painful  joints,  lumbago,  sprains,  etc.,  K-Y  Analge- 
sic will  be  found  to  deserve  a  place  in  the  doctor's  mind — 
and  in  his  bag,  or  on  the  shelf  in  his  office. 


Friction  physiologically  considered  is  a  thing  to  be  avoid- 
ed. Its  proper  antidote  is  lubrication.  The  correct  form  of 
lubrication  calls  for  slipperness  which  is  not  supplied  by 
grease  or  oil.  Furthermore,  grease  or  oil  is  unpleasant  to 
use  and  it  leaves  behind  stains  or  soiled  places  on  the  pa- 
tient's linen,  etc. 

Instruments  of  penetration — such  as  the  sound,  catheter, 
speculum,  scope  or  the  examining  finger,  must  be  lubricated 
and  so  perfectly  lubricated  as  to  slip  easily.  To  pass  such 
an  instrument  deftly,  quickly,  with  a  minimum  of  pain  or 
discomfort  to  the  patient,  requires  perfect  lubrication,  which 
in  turn  enhances  the  manual  dexterity  and  deftness  of  the 
operator.  Patients  are  growing  to  be  increasingly  critical. 
They  note  their  physician's  attention  to  the  "little  things" 
and  judge  accordingly.  Hence  anything  that  will  add  to  his 
skill  or  deftness  must  appeal  to  the  doctor  and  for  that  rea- 
son he  must  be  interested  in  K-Y  Lubricating  Jelly — Fric- 
tion's Antidote. 

This  preparation  is  slippery  but  not  sticky.  It  is  grease- 
less.  It  is  water-soluble.  It  is  transparent.  It  is  non-irri- 
tating.   It  is  convenient  to  use  and  economical. 

Properties  which  v/ill  recommend  it  to  the  discriminating 
doctor  who  has  his  patient's  best  interests  as  well  as  his  own 


240        NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

at  heart.  K-Y  Lubricating  Jelly  is  also  a  valuable  emollient 
and  protective  agent,  in  burns,  scalds,  bed  sores,  chafes, 
dermatitis,  urticaria,  hives,  etc. 

It  relieves  pruritus  in  the  majority  of  instances  and  is  ex- 
ceedingly useful  as  a  soothing  and  protecting  application  to 
the  skin  of  children  suffering  from  scarlet  fever,  measles, 
chicken  pox,  etc. 

K-Y  Lubricating  Jelly  also  keeps  the  surgeons  hands 
smooth,  prevents  bichloride  rash  and  "improves  the  feel." 


Conforming  to  the  rules  of 
the  Council  on  Pharmacy  and 
Chemistry  cf  the  American 
Medical  Association,  we  have 
changed  the  name  of  our  pure 
medicinal  mineral  oil  from 
Stanolax  Liquid  Paraffin  to 


md 

Trade  Mark  Reg.  U.  S.  Pat.  Off. 

Liquid  Paraffin 

(Medium  Heavy) 

Tasteless—  Odorless  —  Colorless 


This  oil  has  won  favor  with  the 
medical  profession  since  its  introduc- 
tion something  over  a  year  ago  by 
reason  of  its  dependability,  its  uni- 
form quality,  its  palatability  and  its 
efficiency  as  a  mechanical  lubricant 
for  use  in  the  treatment  of  intestinal 
stasis  and  other  disorders  where  the 
use  of  mineral  oil  is  indicated. 


If  you  are  unacquainted  with  this 
oil  we  hope  that  you  will  allow  us  to 
send  you  a  trial  quantity.  This  we 
will  gladly  do  upon  request. 

Standard  Oil  Company 

{Indiana) 
72  W.  Adams  £-        Chicago,  U.S.A. 


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ODORLESb 
COLORLESS 

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the  uniformly  satisfactory  results  careful  discriminating  physicians  have  obtained 
in  treating  the  strumuous  disorders  of  all  ages,  have  proven  beyond  all  doubt  that 
this  eligible  remedy  is  unsurpassed  in  its  field  of  activity. 


PARIS 


BATTLE    &     CO. 

ST  .     LOUIS 


LONDON 


Obstetrical  Charts  in  colors,  sent  on  receipt  of  25c  postage  paid.     Ready  for  delw  ery 


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Cerebral 
Sedation 


is  not  infrequently  t'he  first  and  most  essential  detail  of 
scientific  therapeusis,  and  on  its  prompt,  effective  and 
safe  accomplishment  a  patient's  welfare  is  often  wholly 
dependent.  With  so  much  therefore  at  stake,  the  selec- 
tion of  the  hypnotic  or  sedative  agent  to  be  used  is  in- 
variably a  matter  of  more  than  ordinary  importance.  The 


9 


BATTLE  &  CO. 

ST.   LOUIS 


PARIS 


LONDON 


preference  usually  given  by  painstaking  practitioners  to 

BROMIDIA 


is  the  logical  result  of  its  well  established  efficacy  in  re- 
ducing hyper-activity  of  the  cerebral  circulation,  control- 
ling mental  excitation  and  producing  sleep  that  is  nor- 
mal, restful  and  recuperative. 

The  exceptional  quality  of  its  ingredients, 
its  absolute  purity,  constant  uniformity  and 
non-secrecy  are  details  that  have  helped  Bromidia  to 
hold  its  widely  recognized  position  during  the  past 
thirty  years,  as  the  Safest  and  most  dependable 
hypnotic  at  the  command  of  the  medical  profession. 


The  Latest  Word  on  Pellagra 

PELLAGRA 

ETIOLOGY,   PATHOLOGY, 
DIAGONOSIS.  TREATMENT 

By  STEWART  R.  ROBERTS,  A.  B.,  M.  Sc,  M.  D. 

!  Associate  Professor  of  Principles  and  Practice  of 
!  Medicine,    Atlanta    Collegre    of    Physicians    and 
Surgeons ;    Neurologrist    to     Wesley     Memorial 
EHospital,  Atlanta,  Georgia. 

250  Royal  Octavo  Pages-lilustrated-PriceJ^.OO 

—'-^  No  other  disease  is  so  dreaded  today  as  Pellagra.  The 
meager  knowledge  obtainable  about  its  etiology  and  the  un- 
cartain  methods  of  treatmenl  hitherto  prevailing  have  caused 
it  to  be  feared  by  all  who  are  familiar  with  its  ravages.  For 
the  first  time  in  its  history  some  tangible  facts  have  been 
worked  out  along  the  line  of  etiology,  and  rational  methods  of 
treatment  have  been  determined.  Doctor  Roberts  has  studied 
this  disease  in  all  its  phases  in  America,  and  at  the  present 
time  is  completing  personal  observations  of  the  disease  in  its 
natural  habitat,  Italy,  working  out  the  mooted  points  of  etiol- 
ogy and  pathology  with  the  experts  of  Europe.  Personal  in- 
vestigations have  been  conducted  in  the  laboratory  and  in  tlie 
homes  of  the  stricken  victims.  It  is  needless  to  say  that  this 
monograph  will  be  the  latest  word  on  this  subject  and  will  bear 
the  stamp  of  authority.' 

This  Book  will  be  Ready  for  Distribution  January  1,  1912] 

C.   Y.  HOSBY  MEDICAL    BOOK    AND    PUBLISHING  COMPANY 

I   METROPOLITAN  BUILDING.  6raBd  Avenue  and  OllTe  Slreel^  ST.  LOUIS.  U.  S.  A. 


ELEG/VNT 

PHARMACEUTICAL  SPECIALTIES 

Attention  /s  caUed  to  the  EXCELLENCE  and  VALUABLE  THERAPEUTIC 
PROPERTIES  of  these  PREPARATIONS 


Robinson's 
Hypophosphites 

NUTRITIVE,    TONIC,    ALTERATIVE. 

A  Standard  Remedy  in  the  treatment 
of  Pulmonary  Phthisis,  Bronchitis, 
Scrofulous  Taint,  General  Debility,  etc. 
Stimulates  Digestion,  promotes  Assim- 
ilation. 

"D.    Each  fluidounce  contains: 


losphites  Soda  -    -    - 

-  2     grains 

Lime    -    -    • 

V/i       " 

Iron    -    -    - 

-  ly.     " 

Quinine    -    - 

%       " 

Manganese 

-  IVs       " 

Strychnine  - 

1-16      " 

Dose — One  to  four  fluidrachms. 

6  oz.  Bottles,  50  Cents. 
Pint  Bottles,  $1.00. 

This  preparation  does  not  precipitate — 
retains  all  the  salts  in  perfect  solution. 


SALOFORM 

(Flexner) 

Saloform  is  a  definite  Chemical  Compound 
the  component  parts  of  which  are  Hexamethy- 
lene,  Tetramine,  Salicylic  Acid  and  Lythia. 

The  properties  of  Saloform  are  those  of  Uric 
Acid  Solvent  and  of  a  Genito-Urinary  Antiseptic. 

As  a  Uric  Acid  Solvent  it  is  indicated  in  Rheu- 
matism, Qout,  in  Phosphaturia.  in  Gravel,  and 
in  Renal  Colic. 

As  a  Genito-Urinary  Antiseptic  it  limits  sup- 
puration anywhere  along  the  Urinary  Tract, 
from  the  Kidneys  down  to  the  orifice  of  the 
Urethera. 

It  has  been  used  with  most  excellent  results 
in  Pyelitis,  and  Pyonephrosis,  iu  Cystitis,  and 
in  Gonorrheal  and  Non-Qonorrheal   Urethritis. 

SALOFORM  (Flexner)  is  obtainable  in  pow- 
der, tablet  or  elixir. 

Powder  in  1-oz.  vials,  dose  10  grains,  4  times 
daily  (under  physicians  prescriptions),  per  100 
S1.25. 

Tablets,  5  grains,  to  a  bottle,  dose,  2  tab- 
lets 4  times  daily  (under  physicians  prescrip- 
tions): per  100.  $1.25. 

Elixir,  in  16  ounce  bottles,  dose,  teasponful  af- 
ter each  meal  and  at  bedtime  (underphysicians' 
prescriptions),  per  bottle  $2. 00. 

Physicians  who  have  used  Saloform  are  en- 
thusiastic in  their  praises  of  its  merits. 


Robinson's 

LIME  JUICE  and  PEPSIN 

Par«  Concentrated  Pepsin  combined 
with  Pure  Lime  Juice. 

An  exceedingly  valuable  Combination 
in  cases  of  Dyspepsia,  Indigestion,  Bil- 
iousness, Heartburn  and  Mal-Assimila- 
tion. 

APERIENT  AND  CHOLAGOGUB. 

Impaired  Digestion  is  the  consequence  of  a 
sedentary  life,  coupled  with  nervous  and  mental 
strain. 

Reliable  Pepsin  is  one  of  the  best  Digestive 
agents  known.  Pure  Lime  Juice  with  its  aperi- 
ent and  CHOLAGOGUo  characteristics  with  the 
Pepsin  furnishes  a  compatible  and  most  efficient 
combination  as  a  remedy  for  the  disorders 
named. 

Robinson's  Lime  Juice  and  Pepsin  is  pala- 
table and  GRATEFUL  to  the  taste. 

Dose — Adult,  dessertspoonful  to  table- 
spoonful,  after  eating.  Children  one- 
half  toone  teaspoonful,  according  to  age. 

PRICE,    6  oz.  Bottles,  50  Cents. 
16  oz.  Bottles,  $1.00. 


Flexner's 

Solution    of    Albuminate 
of  Iron 

[Liquor  Ferrl  Albuminatis — Flexner) 

Albuminate  of  Iron  is  a  definite  chem- 
ical compound  of  albumen  and  Iron.  In 
the  manufacture  of  the  preparations  of 
this  iron  salt,  we  use  fresh  egg  albumen 
only.  Albuminate  of  Iron  is  the  organ- 
ic compound  present  in  the  red  corpus- 
cles of  the  blood.  It  does  not  disturb 
digestion,  neither  does  it  constipate. 
Contains  in  each  teaspoonful  one  grain 
of  the  Iron  salt,  and  itis  perfectly  stable 
and  bland.  Clinical  experience  has 
demonstrated  its  superiority  as  a  cha- 
lybeate. 

PINT  BOTTLES,  $1.00 

Please  prescribe  ORIGINAL  bottles, 
OUR  label. 


IVf  NOW  MAKE 

rLEXNER'S 


Syrup  Albuminate  of  Iron  Comp. 


[Pints,  $1.00 

Solution  Albuminate  Iron  and  strychnine,  '  Ualf   Pinto 

Syrup  Albuminate  Iron  with  Quinine  and  Strychnine  i  lldll    rllllo 

Please  specify  BOBINSON'S  Original  Bottles.    For  sale  by  Druggists 


SI. 00 


ROBIINSOIN-PEXXE  r    CO., 

(incorporated) 

Manufacturing  Pharmacists  LOUISVILLE,  KY. 

Poucicted  1942.    Incorporated  1890  49~Pamphlets  &raUs  to  Practitioners  by  Mail  upon  reaneet 


The  Briggs  Infirmary 

FOR  THE  TREATMENT  OF  SURGICAL  DISEASES 


THIS  INSTITUTION  is  locatea  in  the  central  part  of  the  city,  easily  accessible  by  several 
lines  of  electric  cars.  Separate  buildings  for  male  and  female  patients,  rooms  well  ventilated 
handsomely  furnished  and  supplied  with  all  the  conveniences  of  modern  hospital  establish- 
ments. Excellent  cuisine  and  competent  trained  nurses.  The  operating  rooms  are  equipped 
with  all  the  requisites  of  modern  operative  surgery.  Rates  of  board  reasonable.  Twenty-Third 
season  opened  September  10,  1915.     For  further  information  address — 

CHARLES  5.  BRIGGS,  A.  M.,  M.  D., 
Or  SAMUEL  S.  BRIGGS,  M.  D., 


Corner  Summer  and  Union  Sts, 


NASHVILLE,  TENNESSEE 


Fellows'  Compound  Syrup 
of  Hypophosphites 

1866-1916 

Not  a  new-born  prodigy  or  an  untried 
experiment,  but  a  remedy  whose  useful- 
ness has  been  fully  demonstrated  during 
half  a  century  of  clinical  application. 

For  50  Years  The  Standard 


B 


Syr.  Hypophos.  Comp.  FELLOWS 


Iteject 


Cheap   and    Inefficient   Subs 
Preparations  "Just  as  Good 


Theo.  Tafel  Co.  i 


W.  E.  ENGLERT,  Prop. 


SURGICAL  INSTRUMENTS,  HOSPITAL  SUPPLIES,     % 
SUPPORTERS  AND  TRUSSES  1 


EVERYTHING  FOR  SICKROOMS 

153     Fourth     Avenue,    North 
NASHVILLE,  TENN. 

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