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NASHVILLE  JOURNAL 


OF 


MEDICINE  and  SURGERY 


C.  S.  BRIGGS,  A.M..  M.D. 

EDITOR  and  PROPRIETOR 


Volume  CXI— January-December,  1917 


NASHVILLE,  TENNESSEE 
1917 


INDEX. 


TABLE  OF  CONTENTS-VOLUME  CXI 


A  Cure  for  Enuresis 13 

A  Simple  Apparatus  for  the  Treatment  of  Incipient  Hip-Joint  Dis- 
ease      ^^ 

Acute   Syphilitic   Meningitis 75 

An  Improved  Substitute  for  Iodized  Catgut  Sutures 76 

Albuminous  Urine 79 

Appendicitis  Complicating  Pregnancy 97 

Ambrine  Treatment  for  Burns 107 

A  New  Diagnostic  Sign  in  Typhoid  Fever 109 

Aneurismal  Obstruction  of  Vena  Cava  Superior  with  Special  Refer- 
ence to  the  Caval  Syndrome 138 

A  Clinical  Consideration  of  Migraine 143 

Arteriosclerosis    1^6 

A  Study  of  the  Menopause 149 

Alcohol  Not  Always  the  Primary  Cause  of  Inebriety 161 

A  Bullet  in  the  Sphenoidal  Sinus 175 

Antisyphilitic  Treatment  of  Pregnant  Women 179 

Appendicitis  Versus  Ectopic  Pregnancy 233 

Abortive  Treatment  of  Typhoid  Fever 234 

Addison's  Disease  in  Girl  of  13 235 

Acupuncture  Vaccination  Method 239 

A  Review  of  Anesthesia  in  Obstetrics 275 

Abdominal   Caesarian   Section 309 

Acute   Appendicitis    332 

Biologic  Diagnosis  of  Pregnancy 18 

Balneotherapy  for  Enlarged  Prostate 43 

Birth  Rate  of  White  and  Colored  Races 144 

Blood  Pressure  in  the  Aged 145 

Blood  Changes  in  Gas  Poisoning 203 

Coddling  of  Children  and  the  Infectiousness  of  Colds 11 

Cancer    Not    Hereditary 46 

Carrel's  Solution  76 

Chronic  Duodenal  Indigestion  in  Children 78 

Conservative  Treatment  of  Eclampsia 81 

Cesarian  Section:     Indications,  Technique,  and  Time  of  Operating. .  Ill 

Charcot's   Joint    148 

Carcinoma  of  the  Breast 176 

Col.  Roosevelt's  Speech  Before  the  American  Medical  Association.  198 

Chiggers 208 


INDEX.  *" 

210 

Delivery  Through  Shell  Wounds ^71 

Diet  in  Typhoid  and  Paratyphoid  Fevers ^^^ 

Death  Following  the  Sting  by  a  Wasp '.*.'.'."."...  301 

Dangers    of    Tonsillectomy ;•■••■* 366 

Damages  for  Result  of  Exposure  to  Cold 

EDITORIAL 21.  58.  85.  113.  150.  180.  211.  244,  278.  311.  339.  368 

Ectopic  Pregnancy    -^^^^ 

SS:Seld^«:r  that  Poly;iactVi;sn;  is'  Usually  •H^:^iu;y: ! ! :  147 

Enterostomy:  a  Perfected  Technic   .....  -^  •  •  •■■■■ ;.  ^^^ „  "^ 204 

Enucleation  of  Eye  with  Implantation  of  Fat  Into  the  Cavity. . . . .  •  ^^^ 

Ether-Chloroform  Mixtures   ^^^ 

Errors  in  Diagnosis-A  Case  and  Its  Lesson \\\\\\\''.''.'.  257 

^peTiences'in  RiconsirucVion'  SurgVry"  of  the  Extremities 300 

i^rly  Ectopic  Pregnancy  Complicated  by  Appendicitis 

Fractures  About  the  Wrist  in  Childhood  and  Adolescence •     ^9 

Fracture  of  the  Base  of  the  Skull ! . ! . .  175 

Fracture  of  Trapezoid 205 

Functional  Tests  in  Chronic  Nephritis 

Full  Term  Ectopic  Gestation  Retained  Eighteen  Years ^^ 

^  .,.  272 

Gout  and  Infectious   Arthritis ^^^ 

Goitre   

50 

Heroin  of  No   Value ^2 

Hj-peridrosis    • 54 

Hematokolpos  in  Woman  of  Seventy-four ^^ 

Heart  Failure  Treated  by  Massage  of  the  Heart •  •  -^^ 

Heart  Murmurs    

Is  Prohibition  a  Practical  Medico-Legal  Question 1 

Is  the  Gall  Bladder  Useless ^ 

Is  Laudable  Pus  Laudable ^^ 

'ZZ^JrT^.er.;,^  -Lun,  •.>•  E.trac.on  o.  ■.ntercc..a.  ^^^ 

Nerves    999 

Injuries  to  Pancreas^. . . .  •  •  •  •  .;^^.^_^- •  •  •  -  —  -  -  —  ^  ^^ 

273 


Injuries  to  Pancreas  Following  Operations  Upon  the  Right  Kidney 


Influenza  Meningitis    ^^^ 

Intestinal    Obstruction    034 

Indicanemia,  Symptom  of  Renal  Insufficiency • 

Indications  for  Interference  in  Pre-Bclamptic  Toxemia ^-' 


iV  INDEX. 

Jaundice  with  Enlarged  Liver  in  a  Young  Adult 205 

Kerosene   Oil  in  Diphtheria , 206 

Local  Anesthesia  in  Surgery  of  the  Colon  and  Rectum 106 

Local  Anesthesia  in  Abdominal  Surgery 142 

Local  Anesthesia  in  Sixty  Cases  of  Chronic  Appendicitis 268 

Myocardial  Efficiency   13 

Musculo-Spiral  Paralysis  Following  Dislocation  of  Shoulder 43 

Marfan's  Epigastric  Puncture  in  Pericarditis  with  Effusion 49 

Magnesium  Sulphate  in  Tetanus 142 

Myoma   and    Pregnancy 209 

Nonprotein  Nitrogen  and  Urea  in  Maternal  and  Fetal  Blood 18 

Nursing  a  Drinking  Man 65 

Non-Venereal  Infection   of  the   Prostate 231 

Nail  Puncture  Wounds  of  the  Foot 231 

New  Method  of  Auscultatory  Percussion  of  the  Chest 238 

Nerve  Blocking  in  Treatment  of  Causalgia 331 

Preventive  Sun  Cure 15 

Pituitary  Extract  in  Obstetrical  Practice 16 

Pregnancy  Toxemia  19 

Pellagra    50 

Progress  in  Our  Knowledge  of  Ovarian  Substance  Therapy 55 

Postmortem  Caesarian  Section 82 

Prostatitis    and    Vesiculitis 140 

Prognosis   169 

Pituitary  Extract  in  Obstetrics 242 

Projectile  in  the   Heart 270 

Removal  of  Stones  from  the  Kidney 44 

Radiotherapy  of  LTterine  Neoplasms 150 

Resuscitation  of  Apparently  Dead  Infant 178 

Results  of  Operation  for  Breast  Tumors 201 

Relationship  Between  Diabetes  and  Cancer 207 

Radiotherapy  Plus  Operation  in  Treatment  of  Concer 230 

Rheumatism  and  Focal  Infection 238 

Relation  of  the  Glands  of  Internal  Secretion  to  the  Female  Pelvic 

Organs    240 

Roentgentherapy  in   Deep-Seated   Malignancy 267 

Results  of  Surgical  Treatment  of  Gastric  Ulcer 302 

Relation  of  Dental  Infection  to  Cancer 335 

Residual  Nitrogen  in  the  Blood  with  Surgical  Disease 365 

REVIEWS  AND  BOOK  NOTICES. 28,  91,  120,  157,  189,  221,  253, 

285,  318,  350,  376 


1 


INDEX.  ' 

subcutaneous  Admiuistration  of  Fresh  Human  Blood 1^ 

Spontaneous  Pneumothorax  in  Pulmonary  Tuberculosis . . . .  •  •  •  ■  •  •     52 

|^[' as  an  "Btiolo^cal  Factor  in  Cirrhosis  'of  the 'Live;! 107 

Surgical  Treatment  of  Acute  Epididmytis ^^^ 

Septic   Sore    Throat 20l 

Spontaneous  Rupture  of  the  Stomach "''.".   202 

Skin  Grafting 236 

Scabies    269 

Sarcoma  of  the  Bowel  in  a  Child ^^^ 

Simplified  Technic  for  Detection  of  Amebas ^^  " " ' ; ; 1.., 

scarlet  R  in  Certain  Diseases  of  the  Conjunctiva  and  Cornea 274 

Some  EtTects  of  Inebriety  -on  the  Teeth  and  Jaws ^^^ 

Status   Epilepticus   in   Pregnancy ^^^ 

Small   Pox  in   Utero ^qq 

Sarcoma  of  the  Rectum 

p 

The  French  Treatment  of  Bums 

The  Treatment  of  Hemorrhoids  by  a  New  Method ^ 

Treatment  of  Boils    (Furunculosis) ^^ 

The  Hand  Sign  in  Syphilis ^^ 

The  Pharmacology  of  Emetine •  • " 

To  Relieve  Pain  in  Incipient  Alveolar  Abscess  or  in  Neuralgia. ...  1-^ 

The  Faucial  Tonsils  in  Singers ^^ 

The  High  Forceps  Application ^q 

Toxemia  of  Pregnancy ;.' '  V- "  "/  '  a„r<^ipVi 

The  Phenolsulphonephthalein  Test  and  Its  Application  to  Surgical     ^^ 

Diseases  of  the  Kidney ^^ 

Tetanus  Relapse  After  Five  Months ^^ 

The  Blister  in  Prostatic  Enlargement • ;  •  • 

Treatment  of  Vincent's  Angina  and  Ulceromembranous  Stomatitis     51 

The  Treatment  of  Amoebic  Dysentery ^^ 

The  Oculocardiac  Reflex  in  Hypothoroidism • ^ 

The  Use  of  Pituitary  Extract  in  Postabortion  Curettage ^* 

The  Care  of  the  Heart  in  Pregnancy ^^ 

Tropical  Diseases  and  Public  Health ^^ 

Twilight  Sleep  in  Obstetrics ^^^ 

Treatment  of  Epithelioma  by  Radium ''"'''■'"   ma 

The  Relation  of  the  Hypophysis  to  Certain  Clinical  Manifestations  109 

The  Effect  of  Cold  on  Malarial  Parasites • 

The  Action  of  Veratrone  in  the  Treatment  of  Eclampsia 179 

The  Mechanism  of  Intestinal  Stasis  in  Children   . ...  •  •  -  ■  -  •  -  •  •  •   ^ 
The  Diagnosis  of   Ureteral  Calculi-A  Plea  for  the  Use  of  the  Wax-  ^^^ 
tipped  Catheter   • 


vi  INDEX. 

Treatment  of  the  Vomiting  of  Pregnancy  with  Ovarian  Extract  and 

Corpus  Luteum    263 

The  Replacement  of  Morphine  in  Surgical  Practice 269 

The  Therapeutic  Use  of  the  Extract  Luteum 276 

The  Treatment  of  Wounds  of  the  Knee  Joint 302 

The  Ultimate  Results  of  the  Operative  Treatment  of  Mammary 

Cancer ^^^  >  ^^^ 

Twilight    Sleep    336 

The  Etiology  of  Mongolian  Imbecility 338 

Uncontrollable  Hiccup  Arrested  by  the  Oculo-Cardiac  Reflex 239 

Vaginal  Plug  in  Ante-Partum  Hemorrhage 242 

Zinc  Chloride  in  Uterine  Hemorrhage 56 


NASHVILLE  JOURNAL 

MEDICINE  AND    SURGERY 

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


Vol.  CXI.  JANUARY,  1917.  No.  1 


Anginal  Olommumrattona 


IS  PROHIBITION  A  PRACTICAL  MEDICO-LEGAL 
QUESTION? 


BV  T.   D.   CROTHERS,   M.D.,   HARTFORD,  CONN.' 


It  would  seem  almost  useless  to  defend  this  resolution  or  to 
stop  and  question  its  practical  application  to  the  solution  of  the 
impending  question.  Yet  strangely  enough  there  are  divergent 
opinions  no  matter  what  the  motive  may  be.  There  are  persons 
who  strenuously  oppose  taking  the  alcoholic  question  into  politics 
and  making  it  an  issue  at  the  polls.  They  seem  to  overlook  the 
great  national  method  of  settling  questions  from  the  beginning 
of  the  American  Republic,  as  well  as  dread,  the  voice  of  the  peo- 
ple when  registered  in  a  formal  legitimate  way.  They  overlook 
the  great  question  that  such  a  measure  is  not  in  deciding  on  the 
merit  or  demerit  and  its  practical  character,  but  is  simply  an  op- 
portunity to  express  individual  opinions  on  the  question.     Every 


*Tliis  is  a  part  of  an  opening  address  delivered  before  the  N.  Y.  Med- 
ico-Legal Society  by  T.  D.  Crothers,  M.D.,  President,  on  the  question, 
"Shall  prohibition  be  submitted  to  a  legal  test  at  the  polls  and  the  re- 
sults of  such  test  be  formulated  in  laws  and  resttrictlons  for  the 
people?" 


2         NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

legislative  body  in  all  the  states  should  most  willingly  pass  meas- 
ures to  submit  the  question  to  the  voters.  Then,  if  they  are  op- 
posed to  the  enactment  of  any  restrictive  measures,  settle  it  by  a 
vote  of  the  people.  These  are  questions  that  should  be  undisputed. 
Every  professional  man  should  favor  measures  of  this  kind  as  the 
first  and  most  important  step  to  solve  the  problem  which  is  pressed 
upon  public  opinion. 

Diiring  the  past  year  some  very  startling  changes  have  occurred. 
Public  opinion  is  clearly  moving  towards  a  complete  abolition  of 
all  sale  of  spirits  as  a  beverage,  and  this  sentiment  is  rapidly  tak- 
ing form  and  shape  in  laws  and  restrictive  measures,  which  show 
evolution  as  well  as  revolution.  What  is  supposed  to  be  a  mere 
fad  and  sentiment  is  coming  to  be  a  reality,  which  must  be  recog- 
nized, and  oppositions  and  denials  will  only  give  it  more  force  and 
power.  Among  the  innumerable  reasons  which  call  for  a  discus- 
sion and  settlement  of  this  question  are  the  startling  conclusions 
which  come  from  a  scientific  study  of  alcohol,  showing  that  the 
theories  of  the  past  have  been  mistaken.  The  supposed  value  of 
alcohol  as  a  stimulant,  tonic  or  food,  is  false  in  every  particvilar. 
The  effects  of  its  use  so  fascinating  has  been  that  of  an  anesthetic 
and  depressant,  covering  up  pain  and  fatigue  symptoms.  When 
examined  in  the  light  of  scientific  studies  all  the  previous  theorie*^ 
of  its  value  and  usefulness  proved  to  be  just  the  opposite,  and  no 
agent  at  present,  excepting  the  poison  of  syphilis^  produces  more 
injuries  and  is  more  prominently  responsible  for  insanity,  crime, 
pauperism,  epilepsy,  feeble  mindedness  and  degeneration,  than 
alcohol.  This  is  not  dependent  on  scientific  studies  alone,  but  is 
supported  by  actual  experience  and  studies  of  the  causes  of  the 
evils  and  conditions  of  life.  In  these  modern  times,  theories  of 
causes  and  conditions  must  bear  the  test  of  actual  examination 
and  critical  study.  They  are  not  accepted  on  the  face  value  which 
evidences  call  for.  Theories  and  dogmas  from  the  past  have  no 
value  unless  sustained  by  the  experience  of  the  present.  In  the 
commercial  Avorld,  where  every  man  is  rated  according  to  his 
physical  and  mental  output  and  capacity  to  do  the  work  assigned 
to  him,  it  is  found  that  the  use  of  alcohol  very  seriously  lowers  his 
capacity ;  even  in  so-called  moderation,  he  is  more  incapable  than 


ORIGINAL  COMMUNICATIONS  3 

the  total  abstainer,  where  exact  services  is  called  for  in  all  depart- 
ments. Actual  experience  shows  that  any  use  of  alcohol  dimin- 
ishes this  output  of  labor  and  mentality.  Thus,  a  business  depend- 
ing on  the  integrit}'  and  vigor  of  the  persons  doing  it,  has  an  in- 
creasing peril  in  the  use  of  alcohol  for  any  puqDose.  This  is  the 
result  of  experience  and  not  theory.  To  such  persons,  prohibi- 
tion is  the  only  question  to  be  considered.  Examples  are  seen  in 
the  railroads  and  large  corporations,  employing  men  for  respon- 
sible positions.  The  life  insurance  companies  furnish  most  start- 
ling evidence  of  the  increased  mortality  from  risks  in  which  there 
is  no  question  except  that  the  insured  uses  spirits  in  certain  very 
limited  quantities.  Statistical  studies  show  that  this  risk  is  a  dan- 
gerous one  and  can  be  stated  in  exact  figures  and  measured  with 
certainty.  In  the  great  questions  of  preventive  medicine,  which 
every  health  board  is  confronted  with,  alcohol  looms  up  as  a  most 
prominent  cause,  either  directly  or  indirectly.  This  furnishes 
another  reason  for  some  different  means  and  measures  of  preven- 
tion, and  suggests  prohibition  as  the  only  possible  alternative.  In 
financial  circles,  mercantile  agencies,  bonding  companies,  banking- 
interests,  call  for  total  abstainers  and  look  with  suspicion  on  any- 
thing less  than  this.  All  these  are  facts  outside  of  the  waves  of 
sentiment  that  has  built  up  great  societies,  church  organizations 
and  moral  movements.  Physicians  and  professional  men,  gener- 
ally hesitate  about  endorsing  the  enthusiastic  waves  of  public 
opinion  based  on  sentiment  and  theories,  hence,  do  not  often  lead 
these  movements  as  they  should,  but  outside  of  all  sentiment  there 
has  come  to  the  surface  a  prohibition  movement  which  can  not  be 
mistaken  and  which  is  going  to  call  for  the  highest  judgment  and 
discretion  of  every  one  in  the  near  future.  It  has  passed  the  em- 
piric stage  and  has  come  now  for  that  of  actual  discussion  of 
facts  and  their  meaning.  The  alcohol  problem,  meaning  by  that 
the  degenerations,  diseases  and  mortality  that  come  from  it,  asso- 
ciated with  it  and  is  a  part  of  its  existence,  has  come  into  the  ho- 
rizon in  such  a  way  that  it  must  be  recognized  and  acted  upon 
as  another  impending  evil  to  civilization.  In  twenty-three  different 
states  of  the  Union  the  sale  of  spirits  is  abolished  by  law,  and  in 
every  other  state  there  is  tremendous  pressure  growing  steadily 


4         NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

to  enact  similar  laws.  It  would  seem  to  be  the  highest  wisdom  of 
our  legislators  to  submit  the  question  to  the  people  at  once  and 
have  a  general  educational  movement  addressed  to  the  voters. 
The  facts  are  numerous  and  accumulating  constantly  which,  if 
understood  by  the  common  people,  would  be  quickly  acted  upon. 
These  facts  appeal  to  the  personal  interest  of  so  many  people. 
They  touch  every  home  and  fireside  and  afifect  so  many  divergent 
interests  as  to  arouse  inquiry  and  call  for  exact  knowledge.  It 
is  very  evident  that  this  last  great  wave  of  public  opinion  is  going 
on  to  the  extent  of  total  abolition  of  the  use  of  alcohol  as  a  bev- 
erage. The  manufacturer  and  dealer  will  be  practically  driven 
out  and  alcohol  will  be  put  to  new  uses.  Already  there  are  inti- 
mations of  this,  in  the  laboratory,  and  most  startling  results,  con- 
firmatory of  previous  opinions  in  local  experiences  in  different 
sections  of  the  country.  An  army  of  exact  workers  are  detennin- 
ing  with  the  exactness  of  a  surveyor,  the  damage  which  comes 
from  the  use  of  alcohol  as  a  beverage  and  an  increasing  army  of 
physicians  are  verifying  this  in  many  ways  and  looking  out  with 
wonder  and  amazement  at  the  future.  A  few  very  special  ob- 
servers have  noted  a  distinct  range  of  causes  farther  back  than 
alcohol,  and,  a  research  hospital  has  been  founded  at  Hartford  to 
take  up  this  subject  and  point  out  conditions  that  call  for  the  an- 
esthesia of  alcohol  and  drugs.  This  is  another  great  forward 
movement  to  show  that  there  is  no  element  of  chance  or  accident 
in  the  things  we  deplore  at  present.  It  is  simply  cause  and 
efifect  and  the  highest  kind  of  scientific  studies  must  concentrate 
on  the  study  of  the  causes  and  the  removal  of  these.  It  would 
seem  from  a  mere  casual  outlook  that  no  kind  of  legislation  is 
more  important  today  than  that  of  submitting  the  prohibition 
question  to  the  people.  It  really  rises  above  all  parties  and  ques- 
tions of  reformers,  pro-alcoholics  and  critical  of  every  kind.  Here 
is  a  reality  that  we  must  meet.  It  is  a  personal  interest  to  do  so. 
It  is  more  than  a  personal  interest,  for  it  is  a  duty  for  us  to  be 
acquainted  with  the  facts  and  in  some  way  show  how  they  can  be 
put  to  service.  There  is  a  French  saying — very  significant — that 
the  subject  is  in  the  air,  meaning  that  consciously  or  unconsciously, 
it  is  here  to  be  settled.     It  is  a  practical  Medico-Legal  question 


ORIGINAL  COMMUNICATIONS  5 

both  generally  and  technically.  A  moment's  reflection  will  show 
how  far  it  affects  the  health  and  vitality  of  the  race,  and  how  far 
it  concerns  the  legal  relations  and  how  thoroughly  practical  it  is 
in  all  its  application  to  every-day  life.  Up  until  a  comparatively 
recent  time,  the  discussion  of  this  question  has  been  along  moral 
and  sentimental  lines  and  the  real  issues  have  been  obscure. 
Now  all  this  has  been  changed.  It  is  a  duty  we  owe  to  ourselves 
and  to  others  to  take  up  the  whole  problem,  to  call  upon  the  medi- 
cal man  in  every  community  to  supply  the  facts  and  educate  the 
people  how  to  vote  wisely  on  a  matter  so  dear  to  their  own  in- 
terests. Our  society  has  long  recognized  this  last  revolution  and 
evolution  in  practical  lif^and  earnestly  urges  that  the  people  be 
prepared  to  vote  on  the  question.  Whatever  the  submission  vote 
may  result  in  it  is  a  movement  to  the  larger  and  better  understand- 
ing of  the  subject.  It  is  only  by  agitation  of  this  kind  that  we 
can  emerge  from  the  delusions  of  the  past  into  the  larger  and 
more  exact  knowledge  of  the  future. 


6         NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


ixttuttB  fvBm  ^nmt  uv^  JFomgn  3ourttals 


SUROICAL. 


The  French  Treatment  of  Burns. 


The  daily  press  and  certain  medical  reports  from  the  European 
fighting  front  have  frequently  mentioned  new  and  successful 
treatment  of  burns  by  French  surgeons.  Since  the  special  dress- 
ing was  known  by  a  coined  word  and  since  its  composition  was 
not  definitely  stated,  the  profession  has  been  awaiting  an  official 
description.  In  the  first  place  it  is  not  very  new,  since  its  employ- 
ment goes  back  to  1904.  It  has  been  in  use  in  the  present  war 
almost  from  the  outset,  but  has  only  recently  come  into  anything 
like  general  employment.  It  consists  of  a  mixture  of  paraffin  and 
resin,  and  while  no  chemical  change  is  set  up  it  possesses  peculiar 
physical  properties  which  make  it  available  for  the  treatment  of 
burns. 

In  the  Archives  de  medecine  et  de  pharmacie  inilitaires  for  Au- 
gust Dr.  Barthe  de  Sanfort  reported  300  burns  in  soldiers  treated 
with  the  remedy,  which  is  described  in  detail.  The  name  "am- 
brine,"  with  which  it  was  christened,  comes  from  its  amber  hue, 
and  seems  to  be  purely  descriptive.  This  surgeon  states  that  he 
first  devised  the  formula  in  1904.  Toussaint  used  it  in  1907  in 
the  military  hospital  at  Lille,  while  another  colleague,  Michaux, 
has  also  had  long  experience  with  it.  Recently  Kirmisson  pre- 
sented some  patients  before  the  Societe  de  Chirurgie  in  which  the 
remarkably  favorable  action  was  well  demonstrated. 

The  substance  is  a  solid  which  fuses  at  about  50°  C.  and  may 
be  sterilized  by  boiling  without  injury.  It  is  applied  hot  (at  70° 
C. — 158°  F.),  causing  no  pain  whatever,  and  even  after  24  hours 
is  still  warmer  than  the  body.  The  favorable  action  is  due  in 
part  to  local  hyperthermia.  Occurring  as  it  does  in  cakes  of  par- 
affin consistency  it  is  broken  up  into  bits  of  various  size,  heated 
to  125°  C.  (257°  F.)  and  then  cooled  to  70°  C.  (1580  F.),  the 


EXTRACTS  FROM  JOURNALS  7 

temperature  of  application.  Its  use  is  not  confined  to  burns  for 
it  is  excellent  in  freezes  and  is  even  superior  in  the  treatment  of 
certain  wounds.  It  is  first  applied  in  very  small  quantities  with 
formation  of  a  thin  pellicle.  Over  this  is  placed  a  very  thin  layer 
of  cotton,  which  is  followed  by  more  of  the  remedy.  This  simple 
dressing  is  painless  and  inexpensive.  It  is  removed  in  twenty- 
four  hours  and  comes  away  en  masse  and  without  pain.  It  is  true 
that  considerable  pus  often  of  foul  odor,  is  found  beneath.  This, 
together  with  loose  sloughs,  is  carefully  wiped  off  and  the  surface 
dried  with  a  hot  air  douche.  The  dressing  is  then  reapplied.  In 
no  type  of  burn  is  it  contraindicated.  In  general,  rapid  healing 
takes  place  with  superior'end  results. — Medical  Record. 

I 

.        i. 


Is  THE  Gall  Bladder  Useless.^ 


This  vesicle  acts  as  a  bulb  to  further  the  passage  of  bile,  regu- 
lating the  pressure  and  serving  as  a  reservoir.  When  the  gall 
bladder  is  removed  the  common  duct  is  dilated  and  in  a  way  be- 
comes a  compensatory  bladder.  Experiments  on  dogs  showed 
that  the  duct  became  dilated  and  even  bulbous  after  cholecystec- 
tomy. Gall  stones  after  cholecystectomy  are  frequent.  For  these 
and  other  reasons,  protest  is  made  against  looking  on  the  gall  blad- 
der as  in  the  same  class  with  the  vermiform  appendix  and  as  un- 
necessary. Cholecystectomy  is  often  mandatory,  but  not  neces- 
sarily the  operation  of  choice  in  all  gall  bladder  and  duct  distur- 
bances. The  gall  bladder  is  not  a  functionless  organ  and  its  re- 
moval should  be  undertaken  only  for  reason,  or,  as  the  author 
puts  it,  "for  truly  great  surgery  is  conservative,  and  radical  only 
when  unredeemable  pathological  lesions  force  her  hand  to  sum- 
marv  action." — Interstate  Medical  Journal. 


Is  Laudable  Pus  Laudable? 


It  is  not  so  long  ago,  remarks  the  Medical  Record,  that  we  used 
to  speak  much  of  laudable  pus,  not  so  long  ago  in  the  history  of 
medicine,  that  is.    Those  of  us  who  are  young  in  years — we  are 


8         NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

all  young-  in  spirit — remember  our  professor  of  surgery  saying 
during  one  of  his  first  lectures  something  like  this,  ''Formerly  it 
was  not  believed  that  a  wound  was  healing  properly  unless  a  quan- 
tity of  typical  creamy  pus  was  present.  This  was  called  'laudable 
pus/  because  it  was  thought  that  it  was  really  beneficial.  Now 
we  know  that  for  a  wound  to  heal  in  an  ideal  manner  there  should 
be  no  pus  whatever."  As  a  matter  of  fact,  the  old-time  doctors 
were  not  so  far  off  after  all.  This  kind  of  pus  to  which  they  re- 
ferred was  usually  a  staphylococcus  infection,  had  little  tendency 
to  spread,  and  showed  an  active  resistance  of  the  tissues  to  the 
infective  organism.  So  that  while  as  a  purely  academic  proposi- 
tion it  may  be  conceded  that  the  ideal  wound  is  a  pusless  wound, 
still  in  actual  practice  it  is  sometimes  better  to  let  the  pus  alone. 

Of  this  opinion  are  Drs.  Donaldson,  Alment  and  Wright,  who 
published  a  report  in  the  British  Medical  Journal  for  August  26th. 
These  doctors  entered  upon  their  military  practice  firm  in  the  be- 
lief that  pus  has  no  place  in  the  modern  surgeon's  scheme  of 
things ;  experience  taught  them  that  in  many  cases  the  pus  should 
be  left  alone,  and  the  patient  would  get  along  the  better  for  it. 
There  did  not  seem  to  be  any  delay  in  healing,  the  patient's  gen- 
eral condition  remained  good,  and  his  pulse  and  temperature 
stayed  down.  The  patients  themselves  were  put  in  a  more  cheer- 
ful frame  of  mind  by  doing  away  with  frequent,  painful  dress- 
ings, and  the  tissues  were  allowed  to  remain  in  a  state  of  rest,  most 
favorable  for  healing.  There  is,  to  be  sure,  an  esthetic  objection 
in  the  odor  arising  from  the  seldom-dressed  septic-case,  but  this 
would  seem  to  yield  in  importance  to  other  considerations. — Medi- 
cal Brief. 


The  Treatment  of  Hemorrhoids  by  a  New  Method. 


Dr.  Louis  J.  Hirschman,  of  Detroit,  Mich.,  read  a  paper  before 
the  late  meeting  of  the  American  Proctologic  Society  in  which  he 
presented  a  simple,  safe  and  efficient  method  of  curing  selected 
cases  of  hemorrhoids  by  the  injection  of  quinine  and  urea  solution. 
During  the  past  two  years  127  patients  have  been  treated  by  this 
method  with  only  one  recognized  failure.     Injection  of  quinine 


EXTRACTS  FROM  JOURNALS  9 

and  urea  in  solutions  of  from  5%  to  20%  strength  produces  star- 
vation and  atrophy  of  the  hemorrhoids.  The  series  reported  in- 
cludes only  uncomplicated  internal  hemorrhoids.  The  results  of 
the  treatment  of  127  patients  justify  the  conclusion  that  the 
method  is  simple,  safe  and  effective  in  properly  selected  cases. — 
Practical  Medicine. 


Fractures  About  the  Wrist  in  Childhood 
AND  Adolescence. 


Burnham  (Annals  of  Surgery,  September,  1916)  from  a  study 
of  fractures  about  the  "wrist  in  adolescence  and  childhood  con- 
cludes that  typical  Colles  fracture  is  very  uncommon  before  early 
adult  life.  In  childhood  (that  is,  before  the  tenth  or  twelfth  year) 
the  common  type  of  fracture  about  the  wrist  is  fractures  of  both 
radius  and  ulna,  either  greenstick  or  complete. 

Separation  of  the  lower  radial  epiphysis  is  of  frequent  occur- 
rence during  the  early  part  of  the  second  decade  and  should  be 
carefully  differentiated  from  dislocation  of  the  wrist,  which  is  so 
rare  as  to  be  a  surgical  curiosity. 

When  fracture  of  the  radius  is  suspected,  either  in  childhood 
or  adolescence,  the  line  of  fracture  should  be  reached  for  at  a 
point  considerably  higher  than  is  the  case  when  the  same  injury 
occurs  late  in  life. 

In  the  case  of  fracture  of  the  lower  end  of  the  radius  in  early 
life  the  frequency  of  the  associated  fracture  of  the  ulna  must  be 
constantly  borne  in  mind,  the  treatment  of  the  condition  being 
modified  accordingly. — The  Therapeutic  Gazette. 


Treatment  of  Boils  (Ferunculosis), 


The  "abortive"  treatment -of  boils  is  recommended  by  Jackson. 
He  moistens  a  toothpick  in  pure  carbolic  acid  and  bores  it  into 
the  center  of  the  funmcle,  or  a  few  drops  of  carbolic  may  be  in- 
jected with  a  syringe. 

As  furuncles  vary  in  their  duration  and  as  some  do  not  come 
to  a  head  at  all  ("blind  boils")  the  expectant  course  of  treatment 


10       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

is  that  recommended  by  many.  An  incipient  boil  should  never  be 
toyed  with.  If  left  alone  it  may  resolve,  if  handled  it  is  always 
sure  to  develop.  As  the  funmcle  forms,  the  surrounding  skin 
should  be  dry  shaved  and  each  boil  covered  with  an  individual 
small  piece  of  soap  salicylic  plaster.  The  latter  should  be  changed 
as  soon  as  any  discharge  collects  underneath  it — say  three  times  a 
day  at  first,  then  every  3  or  4  hours  as  the  core  breaks  down — the 
parts  being  wiped  dry  with  ether  or  benzine  before  each  new  ap- 
plication. By  this  means  the  breaking  down  process  is  hastened 
and  the  production  of  new  boils  prevented. 

Incisions  should  not  be  made  in  the  case  of  ordinary  furuncles 
as  they  simply  become  infected  wovmds  and  are  sure  to  leave  scars. 

In  chronic  furunculosis,  diabetes  or  some  other  serious  consti- 
tutional disturbance  should  be  susp^ected.  In  these  cases  the  best 
results  are  obtained  from  the  injection  of  autogenous  vaccines. 
The  organism  (staphylococcus  aureus)  can  readily  be  recovered 
from  the  pus  by  smearing  the  latter  on  any  ordinary  culture  tube 
(a  diphtheria  tube  does  very  well).  The  vaccine  should  be  pre- 
pared by  a  competent  bacteriologist.  The  dosage  is  determined 
by  the  reaction,  a  week  between  injections  being  the  ordinary  in- 
terval. If  an  autogenous  vaccine  can  not  be  prepared  a  stock 
vaccine  of  mixed  strains  may  also  give  good  results. — The  Med- 
ical Critic  and  Guide. 


The  Hand  Sign  in  Syphilis. 


Posadas  for  the  last  three  years  has  been  noticing  very  often  in 
his  syphilitic  patients,  with  or  without  treatment,  a  pinkish  spot 
in  the  hypothenar  region  of  the  palm.  There  is  evidently  a  special 
dilatation  of  the  capillaries  in  the  skin  of  this  region  on  both 
hands.  It  forms  a  triangle  with  the  base  line  running  from  the 
middle  of  the  inner  half  of  the  first  fold  on  flexing  the  root  of  the 
hand,  to  the  middle  of  the  ulnar  edge  of  the  hand.  The  inner 
side  of  the  triangle  runs  from  the  middle  of  the  ulnar  edge  of  the 
hand  to  the  digitopalmar  folds  corresponding  to  the  little  finger. 
The  triangle  thus  occupies  the  hypothenar  region  but  there  may 
be  merely  a  round  spot  instead  of  a  triangle.    The  skin  may  look 


EXTRACTS  FROM  JOURNALS  U 

pinkish  or  resemble  a  scarlatinal  eruption  or  even  a  vascular  nevus, 
but  the  redness  never  extended  beyond  the  outline  of  the  triangle 
described  above.  He  found  this  hand  sign  in  321  of  493  syphil- 
itics  examined,  that  is,  in  over  65  per  cent,  but  never  earlier  than 
the  third  year  after  infection.  Omitting  the  patients  with  infec- 
tion of  more  recent  date,  he  found  this  sign  pronounced  in  nearly 
81  per  cent  of  397  patients.  Specific  treatment  renders  it  more 
intense  for  the  time  being  and  then  it  returns  to  its  former  aspect. 
— The  Journal  of  the  Am.  Med.  Asso. 


MSDICAL. 


Coddling  of  Children  and  the  Infectiousness 
OF  Colds. 


The  crusade  now  being  undertaken  against  tuberculosis  has 
clearly  brought  to  the  minds  of  every  one  that  the  only  intelligent 
treatment  of  the  disease  is  by  means  of  fresh,  pure  air,  and  a  good 
diet.  In  all  parts  of  the  world,  sanitariums,  conducted  on  those 
principles,  are  springing  up,  and  even  in  England  where  one  would 
think  that  the  climate  was  hardly  suitable  for  the  out-of-door 
treatment,  the  system  is  being  carried  out  on  a  large  scale.  But, 
after  all,  it  should  be  remembered  if  proper  care  is  taken  of  chil- 
dren, when  young,  and  if  their  bringing  up  is  carried  out  more 
with  the  view  of  hardening  them,  and  thus  rendering  them  proof 
against  the  ubiquitous  microbe,  the  need  of  sanitariums  would  be 
much  less  than  is  at  present  the  case.  It  is  a  fact,  both  instructive 
and  pertinent,  that  in  many  of  the  coldest  portions  of  the  globe, 
colds  are  unknown.  Nansen  and  his  men,  when  in  the  Arctic  re- 
gions, although  they  underwent  exposure  of  every  description, 
never  once  suffered  from  colds,  but  no  sooner  had  they  set  foot 
on  their  native  shore  of  Norway,  than  they,  one  and  all,  caught 
severe  colds.  The  experience  of  other  Arctic  explorers  is  the 
same.  It  seems  then,  probable,  that  there  may  be  something  in 
the  theory  of  the  infectiousness  of  colds,  and  that  we  shall  have 
to  give  up  our  traditional  belief  to  the  contrary,  however  much 


12       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

we  may  have  treasured  it.  If  the  infection  theory  be  the  true  one, 
and  if  it  be  frankly  accepted,  a  radical  change  in  the  method  of 
treating  colds  must  necessarily  follow.  If  exposure  is  not  the 
direct  cause,  but  merely  acts  by  so  lowering  the  vitality  that  the 
o-erms  can  gain  an  easy  foothold,  the  radical  treatment  must  be 
to  build  up  and  harden  the  constitution  in  such  a  manner  that  it 
will  refuse  to  harbor  the  seeds  of  disease.  Mothers  and  nurses 
are  too  much  afraid  of  fresh  air  and  ventilation,  but  when  they  un- 
derstand that  the  hot  house  plan  of  rearing  children  will  produce 
a  nation  of  weakly,  delicate  individuals,  susceptible  to  every  com- 
plaint that  is  about,  they  will  doubtless  see  the  error  of  their  ways. 
— Pediatrics. 


The  Pharmacology  of  Emetine. 


Pellini  and  Wallace  in  the  American  Journal  of  the  Medical 
Sciences  for  September,  1916,  state  that  from  their  experience 
they  wish  to  emphasize  the  following  points : 

1.  Emetine  depresses  and  may  eventually  paralyze  the  heart. 

2.  It  is  a  powerful  gastrointestinal  irritant  whether  given  by 
mouth  or  subcutaneous  injection. 

3.  It  causes  a  definite  derangement  of  metabolism,  character- 
ized by  an  increase  in  nitrogen  loss  and  an  acidosis. 

4.  While  in  normal  individuals  given  moderate  doses  these  ac- 
tions may  not  be  of  importance,  in  pathological  states  of  the  cir- 
culation, intestinal  tract,  or  metabolism,  they  may  be  of  a  very 
definite  source  of  danger. — The  Therapeutic  Gazette. 


Te  Relieve  Pain  in  Incipient  Alveolar  Abscess 
OR  IN  Neuralgia. 


Sometimes  the  pain  is  vague  along  one  side  of  the  jaw  and  not 
easily  located.  If  it  is  found  impossible  to  decide  on  any  one  tooth 
as  the  seat  of  the  trouble,  the  pain  may  frequently  be  relieved  by 
taking  some  menthol  crystals,  about  the  quantity  that  would  lie  on 
a  dime,  and  placing  them  in  half  a  teaspoonful  of  water  and  hold- 
ing the  spoon  over  the  gas  till  the  crystals  are  melted  down  in  the 


EXTRACTS  FROM  JOURNALS 


13 


liquid.  Dip  some  cotton  in  the  melted  menthol  and  pack  this 
between  the  cheek  and  gum  on  the  affected  side.  The  menthol  will 
sooth  the  pain  and  frequently  relieve  it  entirely.  This  is  also  an 
excellent  remedy  for  clearing  out  the  head  and  facilitating  the 
breathing  where  the  nasal  passages  are  stopped  up  with  cold.  In 
this  case  pack  the  saturated  cotton  tmder  the  upper  lip.  It  will  be 
found  a  srreat  veMei.— Practical  Medicine. 


A  Cure  for  Enuresis. 


As  a  unique  cure  for  enuresis,  Dr.  Harmon  suggests  that  if  the 
mother  hire  the  child  to  retain  his  urine  for  a  given  time  each  day, 
two,  three,  or  four  houf s,  gradually  increasing  the  time  limit,  that 
the  capacity  of  the  bladder  is  increased,  the  strength  of  the  cut-off 
muscle  is  developed,  the  sensitiveness  is  increased,  and  a  cure  is  the 
result. — Practical  Medicine. 


Myocardial  Efficiency. 


Strickland  Goodall  in  the  British  :\Iedical  Journal  bases  his  con- 
clusions on  the  study  of  2,000  obser\'ations  made  on  healthy  and 
diseased  hearts  during  the  past  five  years.  The  measure  of  a 
heart's  efficiency  is  its  capacity  for  doing  work,  whether  one  is 
dealing  with  a  healthy  or  diseased  heart.  The  physiological  heart 
of  a  healthy  young  adult  responds  to  increased  work  by  increased 
contraction— increased  rate,  blood  pressure,  and  respirations.  In 
the  diseased  heart  in  which  the  myocardium  is  at  all  impaired  the 
response  to  work  is  not  by  increased  contraction,  but  by  dilatation, 
so  that,  although  the  frequency  is  increased  (often  out  of  all  pro- 
portion to  the  amount  of  exercise  taken)  the  blood  pressure  fails 
to  rise  or  actually  falls,  according  to  the  amount  of  damage  present 
in  the  heart  and  the  amount  of  work  done.  The  writer  tested  these 
statements  by  the  following  methods:  the  simple  stair  test,  the 
exerciser  test,  the  inclined  plane  test,  and  the  progressive  exercise 
reaction.  These  various  exercises  have  all  been  found  beneficial 
in  many  cases  of  myocardial  disease  and  when  carried  out  quietly, 


14       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

systematically,  and  over  sufficient  length  of  time  protects  the  sick 
heart  by  estimating  its  limitation  of  power  to  work.— The  Medical 
Brief. 

The  Faucial  Tonsils  in  Singers. 


Irving  W.  Voorhees  has  made  a  determined  attempt  to  obtain 
from  over  a  hundred  physicians  reports  as  to  the  effects  they  have 
found  were  produced  by  tonsillectomies  in  singers.  From  know- 
ledge thus  obtained  and  his  own  experience  he  draws  the  following 
conclusions:  I.  An  analysis  of  5,000  tonsil  operations  in  singers 
shows  that  in  the  hands  of  skilled  operators  there  need  be  no 
special  fear  of  bad  results.  2.  It  is  the  consensus  that  bad  results 
are  most  often  due  to  cicatricial  contractions  occuring  from  care- 
less dissection  or  from  neglected  after-treatment.  3.  Pain  in  the 
tonsillar  region,  neck,  and  larynx,  is  probably  due  to  section  of 
some  of  the  larger  branches  of  the  glossopharyngeal  nerve  (Justus 
Matthews).  4.  Loss  of  singing  voice  after  tonsillectomy  might 
be  due  to  a  nerve  lesion,  but  is  probably  due  to  adhesions  and  cica- 
tricial formations  in  the  fauces.  5.  Loss  of  singing  voice  occurs 
very  rarely  after  tonsillectomy.  Impaired  voice  is  impossible,  but 
most  cases  show  an  increased  range  of  from  one-half  to  a  full  tone. 
6.  The  singers  problem  is  a  very  special  one  and  no  laryngologist 
should  undertake  to  operate  on  these  patients  unless  he  has  some 
knowledge  of  the  art  of  singing.  7.  At  operation  the  greatest  care 
and  skill  must  be  exercised  in  securing  a  clean,  free  dissection. 
Injury  to  the  tissues  surrounding  the  tonsil  may  prove  disastrous. 
8.  Postoperative  care  is  of  special  importance.  The  patient  should 
be  seen  daily  until  full  healing  occurs.— M^rf/ca/  Record. 


Subcutaneous  Administration  of  Fresh  Human  Blood 


For  several  years  Holm  has  injected  fresh  human  blood  sub- 
cutaneously  under  various  conditions  and  for  different  diseases, 
with  apparent  benefit.  In  a  case  of  pernicious  anemia,  under  fre- 
quent subcutaneous  administration,  he  has  seen  the  blood  picture 
o-o  from  30  per  cent  hemoglobin  to  85  per  cent,  and  the  red  blood 


EXTRACTS  FROM  JOURNALS  1» 

cells  rise  from  1,500,000  to  over  4,000,000  in  the  course  of  a  few 
months.  He  says  that  a  fairly  large  amount  of  blood  (4  to  8  oz. 
or  more)  may  safely  be  injected  into  the  subcutoneous  tissues,  and 
perfect  absorption  take  place,  if  ordinary  aseptic  technic  be  em- 
ployed. Blood  which  apparently  is  toxic  to  the  patient  when  used 
intravenously  may  be  injected  subcutaneously  without  causing 
any  undue  reaction,  and  with  apparent  benefit.  Holm  describes 
the  technic  he  has  used  in  hemorrliage  of  the  newborn,  hemor- 
rhage of  gastric  ulcer,  splenomyeloid  of  the  newborn,  hemor- 
rhage of  gastric  ulcer,  splenomyeloid  leukamia  and  in  pernicious 
anemia. — The  Journal  of  the  Am.  Med.  Asso. 


Pr'eventive  Sun  Cure. 


Every  day  one  or  more  groups  of  from  twenty  to  thirty  chil- 
dren gather  at  a  certain  spot  in  their  quarter  where  a  guide  and 
assistant  meet  them  and  conduct  the  party  to  the  banks  of  a  lake 
not  far  from  town.  Here  they  spend  the  afternoon  in  games  and 
gymnastic  exercises,  clothed  only  in  bathing  trunks.  The  aim  is 
to  apply  Rollier's  system  of  heliotherapy  as  perfectly  in  the  lim- 
ited time  afforded  as  is  possible,  and  the  work  is  all  modeled  on 
that  in  his  institution.  It  was  organized  a  year  ago  by  Dr.  L.  Jean- 
neret  for  the  more  delicate  schoolchildren  of  the  city  of  Basel, 
and  it  has  proved  successful  beyond  all  anticipations.  He  adver- 
tised for  helpers  in  the  papers,  asking  young  men  or  young 
women  to  give  up  one  afternoon  in  each  two  weeks  to  a  group  of 
frail  children  to  help  make  them  robust.  Reflection  from  the  lake 
doubles  or  triples  the  effect  of  the  sunlight.  There  were  only  five 
days  during  the  entire  summer  in  which  the  trips  could  not  be 
made  on  account  of  the  weather.  A  group  of  children  too  small 
to  take  the  half-hour  walk  were  provided  with  a  sanded  and 
fenced  space  for  the  purpose  in  one  of  the  public  parks  in  town. 
A  regular  system  was  followed  each  day,  the  walk  to  the  lake, 
then  rest  or  quiet  games,  then  gymnastics  and  games  of  all  kinds. 
Efforts  are  made  to  train  the  children  in  good  habits  of  breathing. 
The  chest  diameter  of  the  two  hundred  children  increased  by  2.03 
cm.  on  an  average  between  July  14  and  September  4,  and  the  av- 


16       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

erage  increase  in  weight  was  825  gni.  Only  four  children  failed 
to  show  this  increase.  The  entire  expense  from  May  to  October 
was  about  twenty-one  dollars.  When  cold  weather  came,  the 
children  had  their  walk  and  the  games,  Saturdays,  but  they  did 
not  remove  their  clothing.  Jeanneret  urges  that  gymnastic  exer- 
cises in  schools  should  be  taken  with  the  trunk  bare  and  in  the 
open  air  when  possible. — La  cure  de  soleil  preventive,  L.  Jean- 
neret, Revue  Med.  de  la  Suisse  Rom.,  April,  XXXXVI,  1916. 


OBSTETRICAL 


Pituitary  Extract  in  Obstetrical  Practice. 


In  American  Medicine  for  August,  1916,  Perry  reports  his  ex- 
perience with  pituitrin.  He  states  that  labor  pains  were  induced 
in  from  three  to  five  minutes,  generally  intermittent  at  first,  but 
became  regular  in  about  fifteen  minutes.  The  contraction  never 
exhibited  the  character  of  spasmodic  pain,  and  he  observed  no 
case  of  tetanus  uteri  in  his  series.  There  were  no  symptoms  in 
either  mother  or  child  to  show  any  untoward  effect  of  the  injected 
drug. 

Delivery  of  the  child  is  hastened  and  expulsion  of  the  placenta 
is  accelerated.  The  uterus  firmly  contracts,  thereby  preventing 
postpartum  hemorrhage,  clot  formation  in  the  uterus,  and  loss  of 
blood. 

An  agreeable  after-effect  of  the  remedy  is  its  favorable  influ- 
ence on  the  evacuation  of  the  bladder;  hence  its  value  in  cases  of 
puerperal  ischuria. 

The  foregoing  are  all  desirable  after-effects,  together  with  the 
apparent  more  rapid  recovery  after  the  hardships  of  labor,  and 
point  to  the  fact  that  pituitrin  is  proving  an  indispensable  remedy 
in  obstetrical  practice.  It  can  be  given  without  danger  to  mother 
or  child,  keeping  in  mind  the  contraindications  of  anatomical  ob- 
struction in  the  birth  canal,  a  too  narrow  pelvis,  nephritis  with  a 
high  blood-pressure,  and  exophthalmic  goitre. 


EXTRACTS  FROM  JOURNALS  17 

Perry  would  be  inclined  to  give  it  late  in  the  second  stage  in  a 
case  whose  history  would  lead  him  to  anticipate  secondary  hem- 
orrhage. 

Lastly,  he  would  advise  against  the  too  early  use  of  pituitrin. 
The  cervix  should  be  well  dilated  and  rigidity  overcome  before 
its  administration ;  any  possible  dangers  may  be  thus  avoided. — 
The  Therapeutic  Gnzettc. 


The  High  Forceps  Application. 


There  still  remains  a  relic  of  bad  practice  in  the  fact  that  the 
attempt  is  sometimes  made  to  deliver  the  unengaged  head  by  for- 
ceps. While  this  may  farely  be  successful,  it  often  fails,  and  the 
unsuccessful  attempt  frequently  leaves  the  patient  wounded  and 
infected.  It  is  difficult  to  eradicate  from  the  mind  of  the  general 
profession  the  belief  that  one  need  not  wait  for  engagement  and 
molding  for  the  successful  application  of  forceps ;  but,  until  this 
is  abandoned,  there  will  remain  from  this  source  a  considerable 
maternal  and  fetal  mortahty  and  morbidity. — The  Journal  of  the 
American  Medical  Association. 


Operation  for  Retrodisplacements  of  Uterus. 


In  the  method  described  by  PJattey  the  round  ligament  is  caught 
in  a  pair  of  forceps  at  a  point  which,  when  drawn  up,  seems  to 
take  up  the  laxity,  and  made  taut.  With  a  needle  threaded  with 
fine  linen  the  proximal  and  distal  ends  are  stitched  together.  This 
gives  us  a  loop  of  the  round  ligament.  A  second  and  third  stitch 
one-half  inch  apart  toward  the  end  of  the  loop  are  introduced 
through  both  sides  of  the  ligament  and  tied,  the  third  stitch  being- 
left  long.  With  a  pair  of  curved  forceps  the  internal  ring  is  en- 
tered and  the  peritoneal  investment  of  the  round  ligament  is  des- 
sected  downward  and  the  peritoneum  is  punctured  at  a  point  as 
near  as  possible  to  the  first  stitch  in  the  ligament.  The  linen 
stitch  left  long  is  caught  in  forceps  and  the  ligament  is  pulled 
through  the  artificial  opening.  With  No.  1  chromic  catgut  the 
lisfament  is  sutured  to  the  under  surface  of  fascia  of  the  rectus 


18       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

by  interrupted  sutures.  The  operation  is,  in  a  measure,  extraper- 
itoneal, and  the  author  says  there  is  no  HkeHhood  of  an  intestinal 
obstruction  taking  place. — The  Journal  of  the  Amer.  Med.  Asso. 


Biologic  Diagnosis  of  Pregnancy. 


In  this  preliminary  communication  Deluca  calls  attention  to 
what  he  calls  the  urine-hemolytic  reaction  as  a  sign  of  pregnancy. 
Tests  with  pig  complement  showed  that  addition  of  urine  from  a 
pregnant  woman  hastened  hemolysis  by  five  or  ten  minutes.  Urine 
from  men  and  from  nonpregnant  women  had  the  opposite  effect, 
retarding  hemolysis.  The  pregnant  urine  lakes  the  red  corpus- 
cles even  without  the  hemolytic  amboceptor,  but  it  took  several 
hours  for  this.  The  presence  of  complement  is  indispensable. 
The  findings  were  constant  in  the  thirty  pregnant  women  exam- 
ined, in  the  second  to  the  ninth  month  of  the  pregnancy.  In  one 
woman  the  hemolytic  reaction  was  pronounced  although  six  weeks 
had  passed  since  an  abortion  at  two  months. — The  Journal  of  the 
American  Medical  Association. 


Nonprotein  Nitrogen  and  Urea  in  Maternal  and 
Fetal  Blood. 


As  nearly  as  possible  the  specimens  examined  by  Slemons  and 
Morris  were  obtained  simultaneously  at  the  end  of  the  second 
stage  of  labor.  The  fetal  blood  was  collected  from  the  placental 
end  of  the  severed  umbilical  cord  which  lead  into  a  sterile  flask ; 
the  maternal  blood  was  aspirated  from  a  vein  in  the  mother's  fore- 
arm. In  thirty-five  normal  obstetric  patients  at  the  time  of  birth 
the  average  rest  nitrogen  in  the  maternal  blood  was  25.2  mg.  per 
100  c.c.  (extremes  18.5  to  33.5  mg.)  ;  in  the  fetal  blood  the  aver- 
age was  24.9  mg.  (extremes  19  to  34.2  m.).  In  sixteen  normal 
patients  the  average  quantity  of  urea  nitrogen  in  the  maternal 
blood  was  10.5  mg.  per  100  c.c.  (extremes  8.4  to  14  mg. )  ;  in  the 
fetal  blood  the  average  was  10.4  mg.  (extremes  7.9  to  13.5  mg.). 
The  urea  nitrogen  represented  44  per  cent  of  the  rest  nitrogen  in 
the  maternal  and  45  per  cent  in  the  fetal  blood.     The  same  con- 


PROCEEDINGS  OF  SOCIETIES  19 

centration  of  urea  in  both  circulations  indicates  that  this  sub- 
stance passes  through  the  placenta  by  diffusion.  Complications 
accompanied  by  an  increase  of  urea  in  the  maternal  blood — toxe- 
mias of  pregnancy,  syphilic,  decompensated  heart  lesions,  and 
others — are  also  attended  with  a  corresponding  increase  in  the 
fetal  blood  urea.  Pathologic  cases  thus  confirm  the  conclusion 
that  urea  diffuses  through  the  placenta.  The  administration  of 
chloroform  during  pregnancy  causes  alterations  first  in  the  fetal 
and  later  in  the  maternal  blood.  Primarily  the  fetal  blood  urea  is 
increased.  Prolonged  anesthesia  causes  a  moderate  increase  in 
the  rest  nitrogen  of  both  circulations.  Asphyxia  dependent  on 
impairment  of  the  fetal-heart  action  is  attended  with  a  notable  in- 
crease in  the  urea  of  the  fetal  blood.  In  cases  of  still  birth  this 
generally  represents  60  to  85  per  cent  of  the  rest  nitrogen. — The 
Journal  of  the  Am.  Med.  Assu. 


Pregn.\ncy  Toxemia. 


Williamson  in  American  Medicine  for  June,  1916,  reaches  these 
conclusions : 

1.  In  cases  of  pregnancy  toxemia  chloroform  should  never  be 
administered,  because  the  action  of  chloroform  is  to  render  more 
grave  the  lesions  which  already  exist  and  increase  the  acidosis. 
Ether  administered  by  the  open  method  is  in  every  way  prefer- 
able as  an  anesthetic. 

2.  Calomel  should  not  be  used  as  an  aperient,  for  the  lesions 
in  the  liver  and  kidneys  produced  by  mercurial  poisoning  are  of 
the  same  nature  as  those  of  pregnancy  toxemia,  and  it  is  probable 
tliat  mercury  even  in  small  doses  will  increase  the  gravity  of  the 
lesion  already  existing. 

3.  For  a  similar  reason  douches  of  mercurial  antiseptics  should 
never  be  employed. 

4.  In  all  cases  in  which  acidosis  is  present  intravenous  infusion 
with  a  solution  of  sodium  bicarbonate  or  sodium  acetate  should  be 
practiced. 

5.  The  fat  metabolism  should  be  spared  as  far  as  possible  by 
the  administration  of  glucose.     Williamson's  practice  has  been  to 


20       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

administer  it  by  the  rectum  when  vomiting  is  present,  and  to  give 
it  by  the  mouth  in  the  form  of  glucose  lemonade  where  the  diges- 
tive functions  are  not  deranged. 

6.  When  a  pregnant  woman  suffering  from  chronic  nephritis 
shows  evidence  of  the  existence  of  acidosis,  the  uterine  contents 
should  be  evacuated  without  delay,  for  with  kidneys  previously 
damaged  the  prognosis  of  pregnancy  toxemia  is  very  grave. — 
The  Therapeutic  Gazette. 


Toxemia  of  Pregnancy, 


The  treatment  of  toxemia  of  pregnancy  by  duodenal  enema  is 
recommended  by  McDonald  (Med.  Rec.)  The  procedure  is  as 
follows :  In  the  first  attempt  it  is  better  to  cocainize  the  patient's 
throat.  The  tongue  is  depressed  with  the  forefinger  while  a  small 
rubber  tube  (12  F)  is  thrust  down  with  the  other  hand,  the  patient 
being  in  the  sitting  posture.  When  the  tube  is  down  about  22 
inches,  8  oz.  of  a  solution  of  sodium  chloride  in  concentration 
somewhat  stronger  than  physiologic  saline,  are  injected  by  means 
of  a  syringe  through  the  tube  into  the  stomach.  This  usually 
overcomes  the  tendency  to  vomit.  The  tube  is  then  thrust  further 
down  to  28  inches.  The  patient  is  then  placed  on  her  right  side 
in  a  semiprone  position.  After  a  few  minutes,  suction  is  made  by 
means  of  a  vacuum  bottle  and  syringe  and  when  bile  is  obtained 
it  is  considered  that  the  tip  of  the  tube  has  passed  the  pylorus. 
This  usually  takes  place  within  5  to  7  minutes.  The  stomach 
should  be  empty  for  several  hours  before  the  treatment  is  given. 

An  injection  is  then  made  by  means  of  a  gravity  can  of  a  liter 
of  a  solution  containing  from  4  to  6  gm.,  by  measure,  of  a  gran- 
ular sodivmi  sulphate.  This  solution  has  the  effect  of  precipitating 
itself  through  the  intestines ;  within  thirty  minutes  of  the  time  the 
last  of  the  sulphate  solution  is  introduced  into  the  tube  the  first 
of  it  appears  at  the  anus.  A  single  treatment  is  all  that  is  required. 
Of  twelve  patients  treated  in  this  manner  only  one  had  any  recur- 
rence of  vomiting. — Medical  Pro^-ress. 


EDITORIALS  *^ 


Sittoml 

Pr....sB.»'s  NoTic^The  Jo«™.l  U  published  In  aowhly  number,    of  «  p.ie. 

TH=:r:;:;  r  ii^.^s'^r^isr  „.«».  ..cb.... ....  .bc.a  b. 

addressed  to  the  Editor. 


Announcement. 


\s  announced  in  the  December  number  of  the  Journal,  on  ac- 
count of  the  increased  cost  of  pubHcation  we  have  been  forced  to 
reduce  the  size  of  the  Journal  from  48  pages  an  issue  to  o2  pages. 
We  re-ret  verv  much  to  have  been  compelled  to  take  this  step, 
but  it  was  a  (luestion  as  to  whether  it  were  the  wisest  course  to 
pursue  rather  than  increase  the  subscription  price.    This  Journal 
was  established  in  1831.  sixty-six  years  ago,  and  has  in  all  that 
time  maintained  the  same  size  and  form.    We  hope,  however,  to 
condense  and  crvstallize  the  reading  matter  so  that  our  publica- 
tion will  be  more  useful  and  practical  to  its  readers  than  ever  be- 
fore    In  all  probabilitv  the  senior  editor  has  been  at  the  helm  lor 
a  lon-er  period  of  vears  than  any  other  living  medical  editor  m 
the  United  States,  it  now  being  forty-one  years  since  he  assumed 
the  editorship  of  the  Journal.     The  associate  editor-^Dr.  W    i. 
Bricro-s—has  recently  moved  to  Lexington,  Ky.,  where  he  will  m 
the^future  devote  himself  to  a  surgical  specialty  in  connection 
with  the  distinguished  surgeon,  Dr.  David  Barrow  of  that  city. 
However,  he  will  continue  his  connection  with  the  Journal  as  as- 
sociate editor  and  will  continue  to  furnish  editorial  matter  and 
occasional  original  articles  as  in  the  past. 

With  the  increased  cost  of  living  and  phenomenal  advances  ot 
prices  in  evervthing  (except  in  the  matter  of  doctor's  fees)  we 
earnestly  ask  that  subscribers  be  more  prompt  in  making  remit- 
tances for  past  due  subscriptions,  or  at  least  notify  the  Journal  to 


22       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

mark  off  their  names  as  subscribers.  This  latter  may  be  done 
with  the  scratch  of  a  pen  and  a  two-cent  postage  stamp.  We  re- 
ally would  regard  it  as  a  favor  and  it  would  save  us  a  great  deal 
of  trouble  for  those  who  no  longer  wish  the  Journal  to  write  us 
to  that  effect.  Unless  we  hear  from  quite  a  number  of  our  read- 
ers who  are  in  arrears  we  shall  drop  them  as  subscribers  from 
now  on.  We  shall  try  to  fulfill  our  obligations  to  our  subscribers 
and  think  it  but  fair  that  they  carry  out  their  part  of  the  contract. 
In  this  season  of  stress  and  high  prices  we  need  all  the  support 
our  friends  can  extend  to  us  and  will  be  grateful  if  they  can  be 
brought  to  realize  that  their  indebtedness  to  the  Journal  is  as  real 
and  as  binding  as  their  debts  for  the  necessities  of  life.  We  ex- 
tend to  our  readers  the  compliments  of  the  season  and  wish  for 
them  all  a  prosperous  and  happy  New  Year. 


Increase  in  Pellagra. 


That  there  may  be  an  increase  in  pellagra  during  the  coming 
year  on  account  of  the  rise  in  the  cost  of  food-stuffs  is  the  fear 
expressed  in  a  statement  issued  by  the  U.  S.  Public  Health  Ser- 
vice today.  As  a  result  of  government  researches  it  was  found 
that  pellagra  is  produced  by  an  insufficient,  poorly  balanced  diet 
and  that  it  can  both  be  prevented  and  cured  by  the  use  of  food 
containing  elements  in  the  proportion  required  by  the  body.  The 
application  of  this  knowledge  greatly  reduced  pellagra  in  1916 
as  compared  with  previous  years.  This  reduction  is  believed  by 
experts  of  the  Public  Plealth  Service  to  have  been  due  to  im- 
proved economic  conditions  which  enabled  wage  earners  to  pro- 
vide themselves  with  a  better  and  more  varied  diet  and  to  a  wider 
dissemination  of  the  knowledge  of  how^  the  disease  may  be  pre- 
vented. It  is  feared,  however,  that  pellagra  may  increase  in  1917 
by  reason  of  an  increase  in  food  cost  out  of  proportion  to  the 
prosperity  now  enjoyed  by  this  country.  The  great  rise  in  the 
cost  of  forage,  particularly  cotton  seed  meal  and  hulls,  is  causing 
the  people  in  many  localities  to  sell  their  cows  and  thus  there  is 
danger  that  they  will  deprive  themselves  of  milk,  one  of  the  most 
valuable  pellagra  preventing  foods.     The  high  cost  of  living  has 


EDITORIALS  23 

further  served  to  bring  about  a  reduction  in  many  families  in  liie 
amount  of  meat,  eggs,  beans  and  peas  consumed,  all  of  which  are 
pellagra  prophylactics.  In  effecting"  economics  of  this  nature  the 
general  public  should  bear  in  mind  the  importance  of  a  properly 
balanced  diet  and  refrain  from  excluding,  if  possible,  such  val- 
uable disease-preventing  foods.  It  is  believed  that  unless  this  is 
done  there  will  be  a  greater  incidence  of  pellegra  next  spring. 


A  New  Medicai,  Journal. 


Dr.  Philip  Skrainka,  for  some  time  connected  in  editorial  ca- 
pacity with  the  Interstate  Medical  Journal,  has  severed  his  con- 
nection with  that  periodical  and  will  in  February  start  a  new  medi- 
cal journal  to  be  known  as  Medicine  and  Surgery.  We  wish  him 
every  success  in  his  venture. 


A  Change. 


The  Louisville  Monthy  Journal  of  Medicine  and  Surgery  will, 
with  the  January  number,  become  the  Mississippi  Valley  Medical 
Journal  and  will  be  the  official  organ  of  the  Mississippi  Valley 
Medical  Association,  the  Ohio  Valley  Medical  Association  and 
the  Louisville  Medico-Chirurgical  Society.  May  it  prosper  and 
increase  in  usefulness ! 


Dr.  J.  W.  Grisard,  of  Winchester,  Tenn.,  a  well  known  practi- 
tioner of  that  city,  died  recently  at  the  age  of  68  years. 


Defective  Teeth. 


Out  of  330,179  school  children  examined  in  the  city  of  New 
York  in  1914,  194,207,  or  58.8%,  suffered  from  defective  teeth. 
This  exceeded  the  sum  total  of  all  the  other  defects  noted  by 
nearly  80,000.  Defective  teeth  impair  general  health  and  impede 
school  progress.  Disorders  of  the  digestive  tract,  tuberculosis 
and  various  other  diseases  frequently  are  preceded  by  diseased 
conditions  in  the  mouth.     There  is  a  direct  relationship  between 


24       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

dental  development  and  mental  development,  and  it  is  absolutely 
essential  to  good  work  in  schools  that  children's  teeth  be  main- 
tained in  a  healthy  cnodition.  The  Public  Health  Service  recom- 
mends that  a  good  tooth  brush  be  included  in  the  list  of  Christmas 
presents  for  every  American  child  and  that  its  use  be  made  a 
part  of  the  daily  training.  If  this  recommendation  is  carried  out 
the  United  States  will  have  more  healthy  children  this  year  than 
last  and  their  chances  of  grov/ing  up  into  useful,  healthy  men  and 
women  will  be  increased. 


Do  You  Know  That 


A  little  cough  often  ends  in  a  large  coffin  ? 

Bodily  vigor  protects  against  colds  ? 

Careless  sneezing,  coughing,  spitting,  spreads  colds? 

Open  air  exercise  cures  colds  ? 

Colds  sometimes  get  well  in  spite  of  the  excessive  use  of  alcoholic 

beverages  ? 

Overheated,  air-tight  rooms  beget  colds? 

Neglected  colds  often  forerun  pneumonia? 

Persistent,  oft  repeated  colds,  indicate  bodily  weakness? 


Symposium  on  the  Medical  Profession. 


The  symposia  wdiich  have  previously  appeared  in  the  pages  of 
the  Medical  Review  of  Reviews — the  Symposium  on  Enthanasia, 
Symposium  on  Sterilisation  of  the  Unfit,  Symposium  on  Drugs, 
and  Symposium  on  Obstetrical  Abnormalities — were  features  of 
interest  and  value,  but  tlie  symposium  which  is  to  appear  in  our 
January  issue  will  be  unique.  It  is  a  Symposium  on  the  Medical 
Profession,  with  contributions  from  distinguished  laymen. 
"What's  the  matter  with  the  doctor?"  is  the  question  that  was 
propounded  and  replies  were  received  from  such  men  of  afifairs  as 
Andrew  Carnegie,  John  Wanamaker,  Nathan  Straus,  Theodore 
N.  Vail ;  from  such  authors  as  Jerome  K.  Jerome,  Israel  Zangwill, 
the  Princess  Troubetskoy,  William  Dean  Howells,  Gertrude  Ath- 
erton,  Robert  W.  Chambers,  Alice  Hegan  Rice,  Margaret  Deland, 


EDITORIALS  25 

Theodore  Dreiser,  George  \\'.  Cable,  Julian  Hawthorne,  Ellis 
Parker  Butler,  Bruno  Leasing,  Booth  Tarkington.  George  Nen- 
nan,  Ernest  Thompson  Seton :  from  such  poets  as  Edith  M. 
Thomas,  Bliss  Carman,  Rose  Hartwick  Thorpe,  Wallace  Irwin, 
Witter  Bynner,  John  Kendrick  Bangs,  (these  last  two  contribu- 
tions being  in  verse),  from  such  folks  of  the  stage  as  Minnie  Mad- 
dern  Fiske,  Wilton  Lackayc,  James  K.  Hackett,  ^^'illiam  C.  de 
Mille,  Charles  Rann  Kennedy,  Eugene  Walter,  John  Philip  Sousa; 
from  such  educators  as  Andrew  D.  White.  David  Starr  Jordan, 

E.  Benjamin  Andrews,  the  late  Booker  T.  Washington.  Charles 

F.  Thwing;  from  such  inventors  as  Nikola  Tesla  and  Hudson 
Maxim;  and  from  editors,  politicians,  cartoonists,  theologians,  et 
al..  throughout  the  world. 

^lany  of  these  contributions  are  literary  gems  from  world- 
famed  masters  of  the  pen,  and  we  believe  they  will  be  quoted  for 
years  to  come. 

We  propose  sending  out  50,000  copies  of  this  January  edition, 
thus  reaching  practically  half  of  the  Medical  profession  in 
America. 


Assistant  Epidemiologist  (Mai.e),  $2,000 — $2,500. 


January  30,  1917. 


The  United  States  Civil  Service  Commission  announces  an  open 
competitive  examination  for  assistant  epidemiologist,  for  men 
only.  From  the  register  of  eligibles  resulting  from  this  examina- 
tion certification  will  be  made  to  fill  vacancies  in  this  position  in 
the  Public  Health  Service,  at  salaries  ranging  from  $2,000  to 
$2,500  a  year,  and  vacancies  as  they  may  occur  in  positions  re- 
quiring similar  qualifications,  unless  it  is  found  to  be  in  the  inter- 
est of  the  service  to  fill  any  vacancy  by  reinstatement,  transfer, 
or  promotion.  Certification  to  fill  the  higher  salaries  positions 
will  be  made  only  from  those  attaining  the  highest  average  per- 
centages in  the  examination. 

The  duties  of  this  position  will  be  to  make  epidemiologic  and 
sanitary'  surveys  to  determine  the  prevalence  and  causation  of 


26       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

disease,  to  conduct  laboratory  studies  in  relation  thereto,  and  to 
recommend  measures  to  prevent  and  control  outbreaks  of  disease. 

It  is  desired  to  secure  persons  thoroughly  competent  in  the  va- 
rious branches  of  sanitary  bacteriology,  and  especially  in  isolating 
the  typhoid  bacillus  from  infected  persons  and  materials. 

Competitors  will  not  be  required  to  report  for  examination  at 
any  place,  but  will  be  rated  on  the  following  subjects,  which  will 
have  the  relative  weights  indicated : 

Subjects  Weights 

1.  General  education  and  medical  training 25 

2.  Laboratory  experience  25 

3.  Experience  in  epidemiological  work 40 

4.  Publications  or  thesis 10 

Total 100 

Graduation  from  a  medical  school  of  recognized  standing,  and 
at  least  three  years'  experience  in  epidemiological  work  under 
Federal,  State,  or  local  authorities,  and  experience  in  laboratory 
technique,  especially  in  regard  to  malaria  and  typhoid  fever,  are 
prerequisites  for  consideration  for  this  position. 

If  a  thesis  is  submitted  under  Subject  4  it  must  be  on  some  san- 
itary subject  upon  which  the  candidate  has  done  special  work. 

Statements  as  to  education  and  experience  are  accepted  subject 
to  verification. 

Applicants  must  have  reached  their  twenty-third  but  not  their 
fortieth  birthday  on  the  date  of  the  examination. 

This  examination  is  open  to  all  men  who  are  citizens  of  the 
United  States  and  who  meet  the  requirements. 

Persons  who  meet  the  requirements  and  desire  this  examination 
should  at  once  apply  for  Form  304  and  special  form,  stating  the 
title  of  the  examination  desired,  to  the  United  States  Civil  Ser- 
vice Commission,  Washington,  D.  C. ;  the  Secretary  of  the  United 
States  Civil  Service  Board,  Postofifice,  Boston,  Mass.,  Philadel- 
phia, Pa.,  Atlanta,  Ga.,  Cincinnati,  Ohio,  Chicago,  111.,  St.  Paul, 
Minn.,  Seattle,  Wash.,  San  Francisco,  Cal. ;  Customhouse,  New 
York,  N.  Y.,  New  Orleans,  La.,  Honolulu,  Hawaii ;  Old  Custom- 
house, St.  Louis,  Mo. ;  Administration  Building,  Balboa  Heights, 


EDITORIALS  27 

Canal  Zone;  or  to  the  Chairman  of  the  Porto  Rican  Civil  Service 
Commission,  San  Juan.  P.  R.  Applications  should  be  properly 
executed,  excluding  the  medical  and  county  officer's  certificates, 
and  must  be  filed  with  the  Commission  at  Washington,  with  the 
material  required,  prior  to  the  hour  of  closing  business  on  January 
30,  1917. 

Issued  December  22.  1916. 


28  REVIEWS  AND  BOOK  NOTICES 


VitimhtB  ntt^  Sank  NutirtB 


Annual  Report  of  the  Secretary  of  the  Navy  for  the  Fiscal  Year  (In- 
cluding Operations  and  Recommendations  to  December  1,  1916). 
1916.     Washington,  Government  Printing  Office,  1916. 

Our  thanks  are  due  to  the  Secretary  of  the  Navy  for  this  ex- 
ceedingly interesting  report.  It  is  a  full  exposition  of  our  nation's 
resources  in  its  navy,  its  present  strength  and  its  great  improve- 
ment in  the  immediate  future.  The  reflex  of  the  great  European 
war  is  clearly  manifested  in  the  great  activity  in  naval  circles.  A 
feature  of  note  in  this  report  is  the  part  devoted  to  Health  and 
Sanitation.  It  is  shown  how  carefully  guarded  are  the  health  con- 
ditions of  young  men  admitted  to  the  navy.  Mortality  statistics 
show  that  while  in  civil  life  eight  out  of  every  thousand  will  die 
from  the  ordinary  hazards  while  in  1915  only  4.48  per  1,000  of 
the  naval  personel  were  lost.  The  standard  requirements  for  ad- 
mission have  been  rigidly  maintained.  The  rigor  of  the  physical 
examinations  is  demonstrated  by  the  statement  that  during  the 
past  year  106,392  sought  admission  to  the  navy.  Of  these  30.18 
per  cent  were  accepted.  This  rigidity  of  physical  requirements 
insures  a  fine  standard  of  men  and  at  the  same  time  lightens  the 
pension  load  of  the  country  in  future  years. 


Progressive  Medicine,  a  Quarterly  Digest  at  Advances,  Discoveries  and 
Improvements  in  the  Medical  and  Surgical  Sciences.  Edited  by  Ho- 
bart  Amory  Hare,  M.D.,  Professor  of  Therapeutics,  Materia  Medica 
and  Diagnosis  in  the  Jefferson  Medical  College,  Philadelphia.  As- 
sisted by  Leighton  F.  Appleman,  M.D.,  Instructor  in  Therapeutics, 
Jefferson  Medical  College,  Philadelphia.  Vol.  IV,  December,  1916. 
Lea  &  Febiger,  Philadelphia  and  New  York.    1916. 

Our  thanks  are  due  the  obliging  publishers  for  this  valuable 
number  of  a  most  excellent  quarterly  publication.  This  quarterly 
stands  in  a  class  by  iself  and  the  up-to-date  physician  can  ill  af- 
ford to  be  without  it.  It  is  most  ably  edited  by  well  known  men, 
and  its  various  departments  are  conducted  by  men  of  world  wide 


NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY  29 

rqiutation  who  know  how  to  thresh  out  the  wheat  from  the  chaff 
and  to  give  the  whole  kernel  from  the  nut  of  all  medical  and  sur- 
gical facts.  When  the  practitioner  reads  this  quarterly,  he  real- 
izes that  he  has  the  very  latest  word  on  all  subjects  treated  of. 
The  subjects  disposed  of  in  this  volume  with  their  respective  con- 
tributors are  as  follows :  "Diseases  of  the  Digestive  Tract  and 
Allied  Organs,  the  Liver,  Pancreas  and  Peritoneum,"  by  Edward 
H.  Goodman,  M.D.,  Philadelphia ;  "Diseases  of  the  Kidneys,"  by 
J.  Harold  Austin,  M.D.,  Philadelphia;  "Genito-Urinary  Diseases," 
by  Charles  W.  Bonney,  Philadelphia ;  "Surgery  of  the  Extremi- 
ties, Shock,  Anesthesia.  Infection,  Fractures  and  Dislocations, 
and  Tumors,"  by  Joseph  C.  Bloodgood.  M.D..  Baltimore.  Md. ; 
Practical  Therapeutic  Referendum,"  by  H.  R.  M.  Landis,  Phila- 
delphia ;  Index.  We  do  not  hesitate  to  recommend  this  quarterly 
to  all  physicians  who  wish  to  keep  up  with  the  progress  of  medi- 
cine and  surgery. 


Depaxtment  of  Commerce,  Bureau  of  the  Census,  Sam  L.  Rogers,  Direc- 
tor, Mortality  Statistics,  1914.  Fifteenth  Annual  Report.  Washing- 
ton Printing  Office,  1916. 

We  are  in  receipt  of  this  important  production  of  the  Bureau 
of  the  Census  of  the  United  States.  It  will  prove  of  the  greatest 
value  to  statisticians  and  sanitarians  as  well  as  to  the  medical  pro- 
fession at  large.  It  is  based  on  transcripts  from  the  records  of 
the  registration  area  which  in  1914  had  an  estimated  population 
of  65,898,295  or  66.8  per  cent  of  the  total  estimated  population  of 
the  United  States.  The  number  of  deaths  registered  was  808,059, 
corresponding  to  a  death  rate  of  13.6  per  1.000  population,  the 
lowest  one  recorded  for  the  registration  area." 


30  PUBLISHERS'  DEPARTMENT 


f  ubltal|Fr's  i^partm^nt 


Chronic  Constipation  of  Infants — Its  Prophylaxis. 


Many  an  infant  is  constipated,  but  just  naturally  "outgrows"  it. 

This  is  usually  the  case  where  the  causative  factor  is  merely 
the  overcrowding  of  the  colon  in  a  small  pelvis,  for  the  size  of  the 
colon  developes  as  time  goes  by  more  slowly  than  does  the  rest 
of  the  body. 

On  the  other  hand,  many  a  chronically  constipated  infant  grows 
up  in  his  ways  into  an  intractably  constipated  adult,  so  that  ana- 
tomic structure  is  not  the  only  consideration. 

Prophylaxis,  therefore,  is  the  thing.  Some  physicians  get  the 
mother  to  hold  the  infant  over  its  chamber  morning  and  night 
immediately  after  feeding,  long  before  it  has  mastered  the  secret 
of  bowel  control. 

As  a  measure  of  prophylactic  training  in  this  connection,  there 
is  nothing  which  will  help  more  than  Interol.  For  without  cathar- 
tic action,  it  lubricates  the  fecal  mass,  soft  and  plastic,  into  the 
sigmoid  and  rectum,  whence  its  expulsion  is  a  comparatively  easy 
matter,  in  the  absence  of  congenital  defects. 

This  measure,  in  conjunction  with  proper  feeding  or  diet  and 
general  hygiene,  will  help  the  infant  or  young  child  to  estaWish 
the  habit  of  regular  stool  so  valuable  to  him  in  later  life. 

Sample  of  INTEROL  and  literature  to  physicians  only.  Van 
Horn  &  Sawtell,  15-17  East  40th  St.,  New  York  City. 


Tonics  Preferable  to  Stimulants. 


In  selecting  a  tonic  it  is  highly  desirable  not  to  mistake  stimula- 
tion for  tonic  action.  Stimulation  means  unduly  exciting  the 
higher  nerve  centers,  suddenly  and  often  excessively  elevating 
the  blood  pressure,  and  providing  a  quick  but  evanescent  effect 
which  rapidly  passes  away  and  is  many  times  more  harmful  than 


NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY  31 

beneficial.  Tonic  action  means  the  gradual  restoration  of  func- 
tional efficiency — "helping  the  body  to  help  itself."  Thus,  Gray's 
Glycerine  Tonic  Comp.  is  a  true  tonic,  with  all  the  advantages 
and  none  of  the  drawbacks  of  a  stimulant.  To  state  it  tersely, 
"Gray's"  is  an  aid  and  a  support  to  body  functions — a  genuine 
prop — not  merely  a  spur  or  lash. 


Chemical  Food  is  a  mixture  of  Phosphoric  Acid  and  Phosphates, 
the  value  of  which  physicians  seem  to  have  lost  sight  of  to  some 
extent  in  the  past  few  years.  The  Robinson-Pettet  Co.,  incor- 
porated, to  whose  advertisements  in  this  issue  we  refer  our  read- 
ers, have  placed  upon  the  market  a  much  improved  form  of  this 
compound,  Robinson's  Phosphoric  Elixir."  It's  superiority  con- 
sists in  its  uniform  composition  and  high  degree  of  palatability. 


"I  used  the  samples  of  Tongaline  Liquid  and  Tongaline  and 
Lithia  Tablets  for  my  wife,  who  was  suffering  from  a  severe  at- 
tack of  the  grippe,  with  such  success  that  she  made  a  prompt  and 
thorough  recovery." 


'T  am  pleased  to  inform  you  that  I  have  had  wonderful  success 
with  Tongaline  during  our  epidemic  of  grippe  here  in  Boston." 


Increases  the  Physiologic  Efficiency 
OF  THE  Stomach. 


In  no  way  is  better  shown  the  trend  of  modern  medicine  to  re- 
vive and  reinforce — rather  than  to  supersede — the  natural  physio- 
logic forces  of  the  body,  than  in  the  present  day  treatment  of  func- 
tional diseases.  Only  a  short  time  ago  there  was  one  routine  com- 
bination that  was  applied  with  almost  religious  fidelity  in  each  and 
every  case  of  stomach  trouble,  and  that  was  pepsin  and  dilute  hy- 
drochloric acid.  Fortunately  an  awakening  came,  and  instead  of 
supplying  an  artificial  digestant,  the  practice  today  is  to  use  meas- 
ures that  encouraare  the  stomach  to  do  its  own  work. 


32  PUBLISHERS'  DEPARTMENT 

Among-  the  therapeutic  agents  that  have  been  found  particularly 
effective  in  this  respect,  Seng  easily  stands  at  the  forefront.  Un- 
der its  use  the  gastro-intestinal  glands  are  stimulated,  fermenta- 
tion is  promptly  controlled,  and  the  distress  and  discomfort  that 
make  the  life  of  the  average  dyspeptic  so  miserable,  rapidly  dis- 
appear. And  because  these  results  are  directly  due  to  the  power 
of  Seng  to  increase  the  physiologic  efficiency  of  the  stomach,  they 
are  not  temporary  and  fleeting;  on  the  contrary,  the  benefits  that 
Seng  produces  are  prolonged,  and  with  removal  of  causative  con- 
ditions, the  improvement  obtained  is  as  permanent  as  it  is  pro- 
nounced. 

It  is  not  difficult  therefore  to  understand  the  place  Seng  has  won 
in  the  regard  of  many  a  physician  as  the  remedy  of  choice  in  all 
atonic  forms  of  indigestion. 


NASHVILLE  JOURNAL 

OF 

MEDICINE  AND    SURGERY 


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


Vol.  CXI.  FEBRUARY,  1917.  No.  2 


Original  (UnmmumraltonB 


THE  PHENOLSULPHONEPHTHALEIN  TEST  AND  ITS 

APPLICATION  TO  SURGICAL  DISEASES 

OF  THE  KIDNEY. 


HOWARD  S.  JECK,  PH.B.,  M.D. 

Surgeon  to  the  Cornell  Clinic,  Department  of  Urology, 
NewYork. 


It  is  indeed  surprising  to  note  the  number  of  men  engaged  in  the 
general  practice  of  bedicine  who  are  either  wholly  unfamiliar  with 
the  phenolsulphonephthalein  test  for  kidney  function  or  who,  hav- 
ing only  a  passing  acquaintance  with  the  test,  do  not  regard  it  as 
being  of  any  particular  value  whatever.  There  are  even  some,  in 
fact,  who  rashly  condemn  it.  While  it  can  not  be  expected  that 
the  refinements  of  the  test  can  be  carried  out  in  the  average  prac- 
titioner's office,  still  there  is  no  question  that  even  by  its  simplest 
application,  much  light  may  be  thrown  upon  many  pathological 
conditions  of  the  urinary  tract,  which  might  otherwise  remain  al- 


34       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

together  obscure.  For  example,  any  urine  containing  pus  with  an 
appreciably  diminished  output  of  phenolsulphonephthalein,  should 
at  once  suggest  an  involvement  of  one  or  both  kidneys.  And  yet 
how  many  men  there  are  who  are  more  than  willing  to  ascribe 
cystitis,  unqualified,  as  the  sole  cause  of  the  patient's  symptoms. 
As  a  means  of  offering  a  fairly  definite  prognosis  in  many  condi- 
tions, the  phenolsulphonephthalein  test  is  very  reliable,  and  when 
the  question  arises  as  to  the  functioning  power  of  a  kidney  whose 
fellow  is  so  diseased  that  nephrectomy  may  be  necessary,  we  have 
yet  to  find  any  one  method  which  gives  us  a  more  satisfactory  idea 
of  the  function  of  the  better  or  sound  kidney. 

The  phenolsulphonephthalein  test  was  originated,  and  studied 
experimentally  and  clinically  by  Geraphty  and  Rowntree  of  Johns 
Hopkins  University.  Since  the  publication  of  the  original  article,* 
a  number  of  clinicians  in  trying  out  the  test  have  gotten  results 
which  compare  most  favorably  with  those  of  the  originators.  For 
the  estimation  of  the  total  output  of  phenolsulphonephthalein  from 
both  kidneys,  the  technique  of  the  test  scarcely  varies  at  all  from 
that  employed  originally  by  Geraghty  and  Rowntree.  However, 
other  investigators  have  contributed  very  materially  to  its  prac- 
tical application,  especially  in  comparing  the  function  of  the  two 
kidneys  in  specimens  obtained  by  ureteral  catheterization.  Not- 
able among  these  contributions,  where  the  method  employed  is  that 
of  injecting  the  phenolsulphonephthalein  intravenously,  is  the  ex- 
cellent article  of  Keyes  and  Stevens,*  who  show  clearly  the  ad- 
vantages of  the  intravenous  administration. 

In  order  to  tempt  those  who  are  skeptically  inclined,  to  give  the 
phenolsulphonephthalein  test  a  trial,  I  shall  at  the  risk  of  tiring 
others  (for  it  has  been  described  so  many  times  before)  attempt  to 
give  briefly  the  technique  of  the  test  as  it  is  employed  today,  both 
for  estimating  total  renal  function  and  comparing  the  output  of 
each  kidney  separately.    In  the  first  instance,  1  c.  c.  of  the  solution 


*Transactions  of  the  American  Association  of  Genito-Urinary  Surgeons, 
Vol.  V,  1910;  p.  59. 

*Transactions  of  the  American  Urological  Association,  Vol.  VI,   1912; 
p.  31. 


ORIGINAL  COMMUNICATIONS  36 

*is  injected  intramuscularly,  preferably  into  the  buttocks,  as  one 
injects  the  various  mercurial  preparations  in  the  treatment  of 
syphilis.  Ten  minutes  are  allowed  to  elapse  (the  time  necessary 
for  absorption  and  appearance  of  the  drug  in  normal  cases)  and 
the  urine  collected  for  the  first  and  second  hour  respectively  from 
that  time.  In  cases  where  it  is  suspected  there  may  be  an  appre- 
ciable delay  in  the  appearance  of  the  drug,  the  bladder  may  be 
catheterized  and  the  time  of  appearance  noted  by  allowing  the 
urine  to  drain  into  a  receptacle  containing  a  drop  of  sodium  hy- 
droxide (about  twenty-five  per  cent  strong).  As  soon  as  the  drug 
appears,  a  pinkish  to  brilliantly  red  color  will  be  noted  as  the  urine 
comes  in  contact  with  the  alkaline  solution.  The  one  and  two  hour 
specimens  may  now  be  collected  from  the  time  of  appearance.  This 
catheterization  feature  of  course  makes  the  test  more  accurate, 
but  is  an  extra  bother  and  except  in  extreme  cases  may  be  dis- 
pensed with.  The  amount  of  phenolsulphonephthalein  is  next 
estimated  in  each  speciman  according  to  the  method  described 
later. 

According  to  Geraghty  and  Rowntree's  original  investigations, 
in  normal  cases  forty  to  sixty  per  cent  of  the  drug  should  be 
excreted  during  the  first  hour  and  twenty  to  twenty-five  per  cent 
in  the  second  hour,  or  a  total  of  sixty  to  eighty-five  for  the  two 
hours.  I,  personally  have  found  the  average  to  be  nearer  the  lower 
figures,  i.  e.,  forty  and  twenty  per  cent  for  the  first  and  second 
hours. 

In  cases  where  it  is  desired  to  compare  the  functional  capacity 
of  one  kidney  with  the  other,  the  intravenous  method  of  adminis- 
tration is  employed  as  follows :    The  ureters  are  first  catheterized, 


*The  preparation  we  use  is  put  up  by  the  Hynson,  Westcott  Company,  of 
Baltimore,  and  contains  6  milligrams  of  the  drug  in  1  c.  c.  Or,  according 
to  Geraghty  and  Rowntree,  it  may  be  prepared  as  follows :  "0-6  gram  of 
phenosulphonephthalein  and  0.84  c.  c.  of-^  No  oH  solution  are  added  to 
0.75  per  cent  na.  cl.  solution.  This  gives  the  mono-sodium  or  acid  salt, 
which  is  red  in  color  and  slightly  irritant  locally  when  injected.  It  is  nec- 
essary, therefore,  to  add  two  or  three  drops  more  of  the  -^  hydroxide,  a 
quantity  sufficient  to  change  the  color  to  a  beautiful  Bordeaux  red.  This 
preparation  is  non-irritant." 


86       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

preferably  with  fairly  large,  flutetipped  ureteral  catheters.  As  soon 
as  the  catheters  begin  to  work  satisfactorily,  1  c.  c.  of  phenolsul- 
phonephthalein  solution  is  injected  intravenously.  It  is  usually 
easiest  and  most  satisfactory  to  employ  the  veins  at  the  elbow  for 
this  purpose.  Care  must  be  taken  to  insure  getting  all  the  solution 
into  the  vein,  otherwise  the  test  will  be  vitiated.  It  is  a  good  plan 
to  fit  the  needle  on  to  the  loaded  syringe  first,  as  the  syringe  offers 
a  convenient  handle  for  manipulation.  Then  after  introducing  the 
needle,  remove  the  syringe  to  see  whether  or  not  blood  will  come 
through  the  needle,  which  it  usually  does  in  drops  at  regular  and 
short  intervals.*  The  syringe  is  again  connected  with  the  needle 
and  the  injection  is  made.  The  time,  from  the  moment  of  injec- 
tion until  the  appearance  of  the  drug  from  the  catheters  is  now 
noted.  The  urine  from  each  catheter  is  allowed  to  drain  into  sepa- 
rate receptacles  containing  a  drop  or  two  of  sodium  hydroxide  as 
in  the  previous  method,  and  the  first  "blush"  carefully  watched  for. 
The  time  of  appearance  is  usually  about  three  minutes.  Specimens 
are  collected  from  each  catheter  for  fifteen  minutes,  and  as  a  rule, 
beginning  with  the  time  of  appearance  in  one  kidney. 

In  intravenous  injection,  the  amount  excreted  for  the  first  fif- 
teen minutes,  is  about  one  per  cent  per  minute  from  each  kidney, 
or  a  total  of  thirty  per  cent.  After  the  first  fifteen  minutes,  the 
amount  of  excretion  falls  off  rather  rapidly. 

From  a  study  of  twenty-six  cases,  where  intravenous  injection 
and  ureteral  catheterization  were  employed,  Keyes  and  Stevens* 
found  that  the  time  of  appearance  may  vary  widely.  In  fourteen 
of  their  normal  kidneys,  it  varied  from  two  to  nine  minutes,  with 
an  average  of  four  and  one  half  minutes.  They  also  found  that 
the  time  of  appearance  may  be  approximately  the  same  for  two 
kidneys  whose  functions  differ  markedly  and  believe  that  "it  is 
peculiarly  misleading  and  should  be  taken  in  consideration  only  for 
the  purpose  of  estimating  the  time  at  which  to  begin  collecting 

*This  is  not  an  absolute  test  of  having  introduced  a  needle  into  the  lumen 
of  a  vein,  since  a  needle  plunged  through  a  vein  will  sometimes  cause  a 
hematoma  from  which  blood  will  flow  in  drops  for  a  few  seconds.  But 
in  the  latter  instance,  the  blood  soon  ceases  to  flow  altogether  or  the  in- 
tervals between  the  drops  very  soon  get  further  and  further  apart. 

*Transactions  of  the    American  Urological  Association,  Vol.  VI,  1912. 


ORIGINAL  COMMUNICATIONS  87 

specimens  for  phenolsulphonephthalein  estimation."  From  the 
same  series  of  cases  they  further  conclude,  that  the  phenolsul- 
phonephthalein output  is  little  if  at  all  influenced  by  oliguria  or 
polyuria,  an  observation  which  seems  to  be  readily  enough  sub- 
stantiated by  the  numbers  of  cases  one  sees  in  which  the  greater 
per  cent  of  the  drug  is  frequently  found  in  the  smaller  volume  of 
two  specimens  of  urine  collected  for  the  same  period  of  time. 

For  total  estimation  of  renal  function,  the  intramuscular  em- 
ployment of  phenolsulphonephthalein  is  not  only  simpler  but  ordi- 
narily more  accurate.  For  here,  one  is  dealing  with  larger  dilu- 
tions of  the  drug  and  longer  periods  of  execretion,  factors  which 
make  for  accuracy  as  "opposed  to  the  errors  which  may  occur  in 
collecting  specimens  of  more  concentrated  dilution,  and  in  much 
shorter  and  more  exact  periods  of  time,  as  is  required  in  the  intra- 
venous method.  Then,  too,  in  the  latter,  as  has  already  been 
pointed  out,  a  drop  or  two,  accidentally  injected  extravenously, 
will  interfere  with  its  accuracy.  But  the  intravenous  method  has 
its  definite  place  in  estimating  separate  renal  function.  In  the  first 
place,  the  intramuscular  method  is  too  long  a  procedure  for  the 
patient  propped  up  in  a  semi-recumbent  posture  with  a  catheter 
in  each  ureter.  But,  most  important  of  all,  is  the  fact  ascertained 
by  Keyes  and  Stevens  that  after  intramuscular  injection  of  phe- 
nosulphonephthalein  inhibition  of  excretion  of  the  drug  occurred 
in  certain  kidneys  following  catheterization  of  the  ureters,  where- 
as such  inhibition  did  not  occur  when  the  drug  was  given  intra- 
venously. 

The  following  brief  report  of  cases*  will  serve  to  illustrate  the 
application  of  phenolsulphonephthalein  in  determining  both  the 
total  functional  capacity  of  "surgical"  kidneys,  and  as  a  means  of 
comparing  the  capacity  of  one  kidney  with  the  other : 

Case  1 — F.  B.  F.  Male.  Age  26.  Of  healthy  appearance.  Gave 
a  history  extending  over  a  period  of  about  two  years,  of  having 
fifteen  or  twenty  sudden  attacks  of  severe  pain  over  region  of  ap- 
pendix. Toward  end  of  this  period,  he  began  to  complain  of  dy- 
suria  and  hematuria,  the  latter  being  more  or  less  intermittent. 

*I  am  indebted  to  Dr.  Edward  L.  Keyes,  Jr.,  with  whom  I  am  associated, 
for  the  privilege  of  publishing  these  cases. 


88       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Urine  Analysis :  Bloody,  Sp.  Gr.  1012,  albumin  1-8  per  cent, 
no  sugar,  many  R.  B.  C,  much  pus  and  a  few  staphylococci.  The 
phenosulphonephthalein  test  (intramuscular  injection)  gave  45 
per  cent  in  the  first  hour,  and  14  per  cent  in  the  second  hour. 

At  a  later  date,  the  patient  was  cystoscoped,  the  ureters  cathet- 
erized  and  an  intravenous  injection  of  phenolsulphonephthalein 
given.    Analysis  of  the  separate  specimens  of  urine: 

Right  kidney:  Left  kidney 

Much  pus.  Mod.  amount  of  pus. 

Phenolsulphonephthlein — none  in  Phenolsulphonephthalein,  (ap- 

13  minutes.  peared   in  3   minutes. 

Urea  0.15  per  cent.  IP/^  per  cent  in  10  minutes 

Urea  0.6  per  cent. 

A  scratch  was  obtained  on  a  wax-tipped  catheter  introduced 
into  the  right  ureter. 

Radiographs  showed  a  large  stone  in  pelvis  of  left  kidney,  a 
large  stone  in  pelvis  of  right  kidney,  together  with  several  smaller 
stones  throughout  kidney,  and  a  shadow  suggesting  stone  in  the 
right  pelvic  ureter. 

The  left  kidney  was  opened  and  a  good  sized  stone,  together 
with  considerable  gritty  debris  was  removed.  About  three  months 
later,  the  right  kidney  was  explored,  found  to  be  a  mere  shell,  full 
of  stones,  and  was  removed. 

It  is  interesting  to  note  that  a  cystoscopy  performed  two  months 
after  the  first  operation,  showed  no  pus  from  the  left  kidney. 

At  first  glance  the  findings  in  the  above  case  seem  to  indicate 
a  discrepancy  between  the  phenonsulphonephthalein  output  and 
the  renal  pathology,  for  the  total  output  is  quite  within  the  normal 
limits.  But  the  separate  output  clearly  shows  which  kidney  was 
the  more  incapacitated  (in  fact  utterly  incapacitated)  and  both 
the  total  and  separate  outputs  bear  testimony  to  the  fact  that  the 
left  kidney  was  quite  capable  of  answering  for  the  work  of  the  two 
combined,  a  fact  attested  to  by  the  splendid  general  appearance  of 
the  patient.  Incidentally  the  picture  also  serves  well  to  illustrate 
how  little  the  functioning  power  of  a  kidney  may  be  disturbed  by 
the  presence  of  a  stone  of  good  size,  provided,  of  course,  no  great 
amount  of  kidney  tissue  has  been  destroyed,  as  was  the  case  in  the 
right  kidney. 


ORIGINAL  COMMUNICATIONS  89 

Case  II — T.  G.  Male.  Age  i7.  Complained  first  of  pain  in 
right  groin,  and  a  short  while  thereafter  of  pain  across  sacrum. 
A  month  later,  he  began  to  have  frequency  of  micturition  with 
pain  at  the  end  of  the  act.  Six  weeks  later,  he  noticed  a  slight 
hematuria.  When  the  parient  presented  himself  for  examination, 
four  months  from  the  beginning  of  his  symptoms,  he  was  urinat- 
ing every  one  or  two  hours  during  the  day. 

Urine  Analysis:  Pale,  cloudy  urine,  Sp.  Gr.  1010,  albumin  1-16 
per  cent,  no  sugar,  many  R.  B.  C,  much  pus,  some  staphylococci 
and  a  moderate  number  of  tubercle  bacilli. 

An  intramuscular  phenolsulphonephthalein  injection  gave  a 
total  output  of  35  per  cent  for  the  first  hour ;  second  hour's  output 
not  noted.  Ureteral  catheterization  showed  pus  and  tubercle  ba- 
cilli from  the  right  kidney ;  no  pus,  no  acid  bacilli  from  the  left 
kidney.     Intravenous  phenolsulphonephthalein  not  done. 

Right  nephrectomy  showed  a  moderately  dilated  ureter  and 
many  obvious  tubercles  of  the  upper  pole.  However  there  appar- 
ently still  remained  a  great  deal  of  nonnal  parenchyma. 

The  patient  made  an  uninterrupted  recovery.  While  the  output 
of  phenolsulphonephthalein  in  the  above  case  is  not  strikingly 
low,  it  is  low  enough  to  direct  attention  to  the  kidneys,  especially 
when  taken  into  consideration  with  the  urinary  findings.  Had 
separate  examinations  been  made,  they  would  doubtless  have 
shown  a  high  output  from  the  left  kidney  with  a  relatively  low 
output  from  the  diseased  side. 

Case  III— E.  W.  Male.  Age  23.  Gave  a  history  of  a  left- 
sided  tubercular  epididymitis  for  two  years.  No  marked  urinary 
symptoms. 

Urine  Analysis:  Pale,  cloudy,  Sp.  G.  1015,  acid,  A.  1-16  per 
cent,  no  sugar,  pus  and  tubercle  bacilli.  Intravenous  phenolsul- 
phonephthalein 2  per  cent  in  first  hour ;  second  hour  not  noted. 

Ureteral  catheterization  showed  pus  and  tubercle  bacilli  from 
left  kidney ;  no  pus,  no  acid  fast  bacilli  from  right.  Left  nephrec- 
tomy. Ureter  dilated  to  size  of  little  finger.  Parenchyma  infil- 
trated with  tubercles  in  all  stages  at  upper  pole,  elsewhere  normal. 

The  right  epididymis  and  left  testicle  were  found  to  be  infected 
and  were  removed.    Recovery. 


40       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Case  IV — Mrs.  J.  A.  Age.  38.  This  patient  presented  herself, 
complaining  of  difficulty  in  urinating  and  hematuria.  These  symp- 
toms had  first  troubled  her  six  weeks  before.  During  the  past 
thirteen  years  she  had  undergone  three  operations,  one  for  an 
ectopic  gestation,  one  for  prolapse  of  the  viscera,  and  finally,  an 
abortion  of  a  three  months'  foetus  because  she  could  not  urinate. 

The  patient  had  lost  25  pounds  in  a  year's  time.  Physical  ex- 
amination revealed  a  large,  moderately  adherent,  low  kidney  on 
the  right  side.  The  bladder  was  found  to  contain  large  blood  clots, 
which  explained  in  large  measure  her  difficulty  in  urination,  as 
these  clots  would  actually  block  the  urethra. 

An  intramusclar  phenolsulphonephthalein  test  gave  35  per  cent 
in  the  first  hour  and  16  per  cent  in  the  next  twenty  minutes.  A 
cystoscopic  examination  was  made  before  all  the  intramuscular 
phenolsulphonephthalein  had  been  eliminated.  However,  speci- 
mens were  collected  from  each  ureter  anyway,  that  from  the  right 
side  showing  only  a  trace  of  phenolsulphonephthalein  in  ten  min- 
utes, while  the  left  side  excreted  5  per  cent  in  ten  minutes. 

The  right  kidney  was  removed  the  day  following  the  cystos- 
copy, and  revealed  a  very  large  non-adherent  hypernephroma 
chiefly  involving  its  lower  pole.    Convalescence  uneventful. 

It  is  worthy  of  note  that  while  5  per  cent  of  phenolsulphoneph- 
thalein would  not  be  considered  a  good  output  from  one  kidney 
after  intra-venous  injection,  it  is  unusually  good  after  intra-mus- 
cular  injection,  especially  during  the  second  hour's  excretion. 

Case  V — Mrs.  A.  E.  T.  Age  44.  Gave  a  brief  history  to  the 
effect  that  she  had  pain  in  her  left  side  for  three  months.  Re- 
mained in  hospital  two  weeks  prior  to  operation  without  any  rise 
of  temperature.  Urine  full  of  pus.  A  total  phenolsulphoneph- 
thalein test  gave  10  per  cent  for  the  first  hour  and  10  per  cent  also 
for  the  second  hour. 

Ureteral  catheterization  showed  much  pus  and  0.4  per  cent 
urea  (4  grams  to  litre)  from  the  left  side,  and  a  very  little  pus, 
and  1.2  per  cent  urea  (12  grams  to  litre)  from  the  right  side. 

Under  local  anesthesia,  the  lower  pole  of  her  left  kidney  was 
"tapped"  and  a  large  quantity  of  pus  evacuated.  The  patient  was 
up  in  ten  days,  and  a  cystoscopic  examination  three  months  later 


ORIGINAL  COMMUNICATIONS  41 

showed  a  normal  bladder  with  normal  ureteral  orifices.  She 
seemed  perfectly  well. 

Fi  om  such  a  low  total  output  as  is  shown  in  the  foregoing  case, 
one  might  conclude  ver>^  properly  that  both  kidneys  were  involved, 
as  indeed  they  were,  though  the  infection  of  the  one  side  was  quite 
mild  as  compared  with  the  other.  In  this  instance,  the  urea  out- 
put indicated  quite  accurately  the  badly  diseased  kidney.  The 
case  is  of  further  interest  in  that  a  cure  was  affected  by  means  of 
nephrotomy. 

The  bacteriologist  reported  the  infection  as  probably  due  to  the 
bacillus  dysentericus. 

TECHNIQUE  OF  ESTIMATION. 

Originally,  a  very  exact  and  quite  expensive  instrument,  called 
the  Duboscq  Colorimeter,  was  used  for  this  purpose.  But  this  has 
been  largely  discarded  in  favor  of  other  simpler  and  less  expen- 
sive instruments.  The  latter,  while  not  so  exact,  are  exact  enough 
and  are  becoming  more  popular  on  account  of  the  price.  The 
Dunning  Colorimeter,  one  of  the  latest,  simplest  and  cheapest,  is 
well  adapted  to  the  needs  of  most  of  us.  It  consists  of  a  series  of 
sealed  ampules  about  15,  containing  different  strengths  of  phenol- 
sulphonephthalein  in  alkaline  medium.  The  solution  to  be  tested 
is  put  into  an  open  ampule,  made  for  the  purpose,  and  the  shale 
and  density  of  the  specimen  is  compared  with  that  of  the  other 
ampules  until  one  is  found  which  matches  the  specimen  the  nearest 

The  entire  quantity  of  urine  representing  this  specimen  to  be 
estimated  is  diluted  to  about  200  c.  c.  with  water  and  rendered 
alkaline  by  the  addition  of  a  5  per  cent  solution  of  sodium  hy- 
droxide (however,  most  any  alkaline  solution  will  answer  the  pur- 
pose). It  is  then  further  diluted  with  water  enough  to  make  one 
litre.  The  open  ampule  is  then  filled  with  some  of  the  latter  solu- 
tion and  comparisons  made.  If  the  specimen  matches  the  ampule 
marked  30  or  50,  for  example,  then  the  reading  is  30  per  cent  or 
50  per  cent  as  the  case  may  be,  since  the  test  ampules  are  all  based 
on  a  solution  made  by  diluting  1  c.  c.  of  the  standard  phenolsul- 
phonephthalein  solution  up  to  1,000  c.  c.  of  water. 

If  only  a  slightly  reddish  coloration  is  obtained  after  adding  the 
alkaline  solution,  it  indicates  that  the  phenolsulphonephthalein  con- 


42       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

tent  is  small  and  hence  dilutions  should  be  carried  only  to  250  or 
500  c.  c.  or  even  smaller  fractional  parts  of  1,000.  The  reading 
should  then  be  divided  by  4  or  2  or  a  higher  figure  as  the  case  may 
be. 

The  presence  of  blood  in  the  urine  sometimes  makes  an  accu- 
rate reading  impossible.  By  centrifuging  the  urine,  and  discard- 
ing the  sediment,  this  difficulty  may  be  obviated,  though  the  accu- 
racy of  the  test  is  of  course  influenced  to  some  extent  by  this  pro- 
cedure. Urines  which  are  cloudy  from  pus  or  other  causes,  may 
be  rendered  clear,  sometimes  by  filtering  or  better  by  adding  basic 
lead  acetate,*  and  filtering.  This  precipitates  various  salts  in  the 
urine  which  carry  down  the  pus,  etc.,  with  them.  The  phenol- 
sulphonephthalein  is  not  precipitated. 

PHENOSULPHONENHTHALEIN   IN   NEPHRITIS. 

In  closing,  a  word  or  two  about  the  employment  of  phenolsul- 
phonephthalein  as  a  test  in  the  ordinary  nephritis  cases  (the  "med- 
ical" kidneys)  would  perhaps  not  be  out  of  place.  Geraghty  and 
Rowntree,  in  their  original  article,  claim  almost  as  much  for  its 
use  as  a  functional  test  in  the  latter  as  they  do  in  the  case  of  the 
"surgical"  kidney,  laying  especial  emphasis  on  its  value  in  acute 
nephritis  and  in  differentiating  true  nephritis  from  obscure  con- 
ditions which  resemble  the  latter  clinically.  They  cite  several 
clear  cut  cases,  which  seem  to  substantiate  their  view. 

But  there  is  still  much  difiference  of  opinion  among  internists 
as  to  the  real  value  of  any  one  functional  test  in  nephritis.  This 
can  be  well  understood  when  it  is  considered  that  the  classifica- 
tion of  the  different  forms  of  nephritis  is  yet  quite  hazy  and  is 
constantly  undergoing  more  or  less  change.  On  theoretical 
grounds,  however,  it  would  seem  that  phenolsulphonephthalein 
could  be  employed  with  advantage  in  cases  of  tubular  nephritis 
(formerly  and  improperly  known  as  parenchymatous  nephritis), 
but  would  be  unreliable  in  glomerular  nephritis  (interstitial  neph- 
ritis) since  Geraghty  himself  states  that  the  drug  is  excreted  by 
the  tubules  of  the  kidney,  the  glomeruli  taking  little  or  no  part  in 
its  elimination. 


*Geraghty  and  Rowntree.    Transactions  of  the  American  Association  of 
Genito-Urinary  Surgeons,  Vol.  V,  1910. 


EXTRACTS  FROM  JOURNALS  48 

ExtrartB  tvam  fome  anii  JFurFtgn  ianvmis 


SURGICAL 


Balneotherapy  for  Enlarged  Prostate. 


Fernandez  reports  the  case  of  an  elderly  man  with  hypertro- 
phied  prostate  causing  intense  reflex  phenomena  and  polyuria, 
with  pains  before  and  after  micturition,  the  desire  returning  every 
ten  minutes  on  an  average,  rest  at  night  being  impossible.  He 
had  tried  all  kinds  of  measures  but  without  avail.  Fernandez  then 
ordered  baths  the  same  as  for  uterine  trouble,  ten  or  twelve  baths 
of  ten  minutes  each,  with  the  water  at  45  C.  (113  F.).  After  the 
first  bath  conditions  were  improved  so  much  that  two  hours  elapsed 
before  micturition  became  necessary.  By  the  end  of  sixteen  days, 
the  cure  seemed  complete,  there  being  no  further  pains  and  the 
intervals  approximately  normal.  This  condition  has  persisted  for 
two  months  to  date.  ( Fernandez  gives  no  details  of  the  technic 
for  the  baths  a  la  prostata,  except  that  they  were  taken  "according 
to  his  method."    He  practices  at  Vichy  Catalan,  Spain.) 


Musculo-Spiral  Paralysis  Following  Dislocation  of 
Shoulder.    Patient. 


"I  had  rather  an  unusual  experience  in  having  two  of  these  cases 
come  into  my  service  on  the  same  day  about  six  months  ago.  Both 
of  them  had  dislocations.  Both  had  musculo-spiral  paralysis.  One 
case  began  to  show  steady  signs  of  improvement  after  reduction, 
and,  until  I  lost  track  of  him,  he  made  quite  an  appreciable  ad- 
vance. In  the  other  case  I  happened  to  follow  the  patient  for  two 
or  three  months  and  there  was  no  evident  sign  of  improvement. 
I  feel  the  history  of  most  of  these  cases  is  that  after  about  a  year, 
unless  there  has  been  great  damage  done  to  the  nerve,  you  get  a 
pretty  satisfactory  ability  to  use  the  arm."— Long  Island  Medical 
Journal. 


44       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 
Tetanus  Relapse  After  Five  Months, 


Heichelheim  states  that  at  the  outbreak  of  the  war  before  pro- 
phylactic antitoxin  had  come  into  general  use,  relapse  in  tetanus 
was  so  infrequent  that  he  could  find  but  two  recorded  cases.  He 
himself  has  seen  a  case  during  the  present  year  in  which  by  chance 
a  wounded  soldier  failed  to  get  his  prophylactic  injection.  Twelve 
days  after  a  shell  fragment  wound  over  the  sacrum  the  disease 
announced  its  presence.  It  was  localized  at  first  in  the  left  thigh. 
Intensive  treatment  was  at  once  began  with  antitoxin,  magnesium 
sulphate,  morphine,  etc.  Severe  anaphylactic  shock  was  met 
promptly  with  camphor  injections.  The  entire  outbreak  was  soon 
under  control,  while  the  patient  was  free  from  spasms  in  one 
month  after  the  day  of  injury.  In  about  three  and  one-half 
months  it  became  necessary  to  remove  a  piece  of  bone  at  the  site 
of  the  wound,  and  twelve  days  after  operation  there  was  a  second 
outbreak  of  tetanus,  a  duplicate  of  the  first,  which  had  been  of 
the  socalled  inferior  type,  manifested  chiefly  in  both  lower  ex- 
tremities. For  fear  of  anaphylaxis  serum  was  not  injected  save 
for  small  quantities  in  the  muscles  and  in  the  wound.  The  patient 
made  a  slow  recover)^  and  was  not  free  from  spasms  for  several 
months.  This  case  differs  in  type  from  those  in  which  a  spontan- 
eous relapse  occurs,  for  the  disease  was  evidently  lighted  up  by 
an  operation  which  must  in  some  way  have  mobilized  a  latent 
condition. — Medical  Record. 


Removal  of  Stones  from  Kidney. 


From  January  1,  1908,  to  December  31,  1915,  450  patients  with 
stone  in  the  kidney  were  operated  on  in  the  Mayo  Clinic  (484 
operations).  Three  died,  a  mortality  of  0.6  per  cent.  This  per- 
centage represents  the  number  of  patients  who  died  in  the  hos- 
pital without  regard  to  cause  of  death  or  length  of  time  after 
operation.  Mayo  says  that  the  results  achieved  were  due  more 
to  the  painstaking  care  with  which  the  diagnosis  were  made,  the 
function  of  the  kidney  estimated,  and  the  patients  prepared  for 


EXTRACTS  FROM  JOURNALS  45 

operation,  than  to  any  purely  technical  feature  of  the  procedures 
employed  in  removing  the  stones.  The  presence  of  the  stones  was 
shown  by  the  roentgenogram.  By  means  of  the  pyelogram  the 
urologist  was  able  to  say  with  certainty  whether  the  stone  was  in 
the  pelvis,  calyx,  or  parenchyma  of  the  kidney.  Forty-eight  pa- 
tients (9.9  per  cent)  had  stones  in  both  kidneys.  In  these  cases, 
the  second  kidney  was  found  pyonephrotic,  a  condition  necessitat- 
ing nephrectomy.  In  three  instances  stones  were  found  in  a  single 
kidney  and  in  two  instances  in  a  horseshoe  kidney.  The  condition 
was  diagnosed  before  operation  as  nephrolithiasis  in  an  anomalous 
kidney.  In  one  case  of  horseshoe  kidney  the  stone  had  caused  a 
pyonephrosis  in  the  left  half.  This  portion  of  the  kidney  was 
resected  and  recovery  followed.  Renal  stones  were  found  in  two 
patients  with  duplication  of  the  renal  pelves.  In  both,  the  caudal 
pelvis  was  involved ;  in  one,  a  pelviolithotomy  sufficed  but  in  the 
other  resection  of  the  upper  half  of  the  kidney  was  necessary. 

There  were  two  cases  of  stones  in  the  remaining  kidney  after 
nephrectomy.  ^Multiple  stones  in  the  parenchyma  of  the  kidney 
are  prone  to  recur.  In  one  case  in  which  Mayo  removed  twenty- 
eight  stones  from  one  kidney  and  twenty-six  from  the  other,  he 
reoperated  on  the  patient  within  two  years  for  stones  in  both  kid- 
neys. The  following  operations  were  performed:  pelviolithot- 
omy, 206  cases;  combined  pelviolithotomy  and  nephrolithotomy, 
34  cases ;  nephrolithotomy,  40  cases  and  nephrectomy,  204  cases. 
— The  Journal  of  the  Amer.  Med.  Asso. 


A  Simple  Apparatus  for  the  Treatment  of  Incipient 
Hip- Joint  Disease. 


The  two  essentials  in  the  treatment  of  hip- joint  disease  are  ex- 
tension to  separate  the  surfaces  of  the  joint  and  immobilization  of 
the  joint. 

The  author  uses  an  extension  apparatus  at  night  which  consists 
merely  of  a  boot  made  of  plaster  and  laced  down  the  front  so  that 
it  may  be  readily  removed  in  the  morning  and  replaced  at  night. 
To  the  foot  of  the  cast  is  attached  a  cord  and  weight.     For  day 


46       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

use,  there  is  a  high  foot  and  a  pair  of  crutches.  The  weight  of 
the  lead  keeps  the  hip  extended  and  fixed.  The  child  is  thus  kept 
in  the  open  air  all  day  long. — Pediatrics. 


Cancer  Not  Hereditary. 


The  annual  meeting  of  the  American  Association  of  Life  In- 
surance Presidents  was  held  in  New  York  City  on  December  15. 
In  a  paper  on  heredity  of  cancer  based  on  a  two-year  study  of  orig- 
inal insurance  statistics  bearing  on  the  eighty  thousand  annual 
deaths  from  this  disease  in  the  United  States,  Mr.  Arthur  Hunter, 
president  of  the  Actuarial  Society,  says :  There  seems  little  to 
support  the  view  that  cancer  is  the  result  of  contagion.  Twenty 
thousand  applications  for  insurances  were  reviewed  and  it  was 
found  that  in  488  cases  one  only  of  the  parents  of  the  applicant 
was  stated  to  have  died  from  cancer  and  in  four  cases  both  parents 
were  stated  to  have  died  of  that  disease.  There  were  122  times 
as  many  cases  in  which  one  parent  had  died  of  cancer  as  those  in 
which  both  parents  had  died  of  that  disease.  There  could  hardly 
be  a  stronger  test  than  in  the  case  of  husband  and  wife.  Men 
and  women  who  are  in  anxiety  of  mind  on  account  of  the  appear- 
ance of  cancer  in  their  ancestry  or  immediate  family  may  dismiss 
such  anxieties,  as  there  is  no  statistical  evidence  at  the  present 
time  that  the  disease  of  cancer  is  transmitted  by  inheritance  in 
mankind. — Nezu  Orleans  Medical  and  Surgical  Journal. 


Fracture  of  the  Base  of  the  Skull;  Early  Double  Subtem- 
TEMPORAL  Trepanation;  Recovery. 


Meriel  E.  (Boston  Medical  and  Surgical  Journal),  points  out 
that  early  operative  interference  in  fractures  of  the  base  of  the 
skull  is  exceptional.  The  field  is  difficult  to  approach  for  cleans- 
ing and  disinfection  and  besides  the  dangers  concomitant  to  op- 
eration are  perhaps  as  great  as  those  due  to  the  lesion.  Meriel 
differs  from  this  view  and  reports  a  case  to  show  that  benefit  can 


EXTRACTS  FROM  JOURNALS  4T 

follow  a  simple  and  rapid  operation  even  in  cases  which  are  con- 
sidered beyond  the  resources  of  surgery. 

In  a  very  severe  case  of  fracture  of  the  vault  irradiating  to  the 
base  with  hemorrhage  from  the  nose  and  mouth,  he  practiced  an 
early  bilateral  subtemporal  trepanation,  decompressing  and  drain- 
ing the  cranial  cavity.  The  technique  followed  was  that  of  Le- 
jars.  Immediate  benefit  resulted.  The  clonic  convulsions  ceased, 
circulation  became  regulated  and  the  temperature  approached  nor- 
mal. There  was  only  slight  subcutaneous  suppuration.  The  man 
rapidly  improved.  Meriel  advises  the  operation.  Chudovsky  in 
1898  gave  the  mortality  in  non-reported  cases  of  base  fractures  as 
64.2  per  cent.  Cushing-in  operated  cases  had  13  recoveries  in  15 
cases  and  Vincent  7  recoveries  in  7  operated  cases — Medical 
Progress. 


Value  of  Nerve  Suture  In  War  Surgery, 


Drs.  Chiray  and  E.  Roger  reported  to  the  Societe  medicale  des 
hopitaux  de  Paris  on  cases  of  nerve  suture.  They  insist  that  in 
order  to  draw  valuable  conclusions  it  is  necessary  to  classify  the 
observations  carefully  and  to  base  them  only  on  cases  of  nerve 
suture  after  complete  section.  Chiray  and  Roger  found  that  nerve 
suture  is  followed  by  negative  results  in  29  per  cent  of  the  cases ; 
sensory  response  to  electric  stimulation,  without  motor  response, 
occurs  in  48  per  cent.,  and  motor  and  sensory  restoration  occurs 
in  23  per  cent.  Return  of  sensation  always  precedes  return  of 
motion.  Alotion  returns  in  the  radial  nerve  after  five  months,  in 
the  ulnar  after  eight  months,  in  the  median  after  seven  months, 
in  the  sciatic  and  popliteal  after  two  to  five  months.  The  radial, 
sciatic  and  external  popliteal  nerves  seem  to  give  the  best  results. 
Experience  has  shown  that  early  operation  is  the  most  effective; 
nevertheless,  operations  performed  at  the  fourth  or  the  sixth 
month  are  often  successful.  Chiray  and  Roger  emphasize  the 
importance  of  total  resection  of  all  fibrous  tissue,  coaptation  of 
the  severed  ends  without  tension  and  without  bruising.  The  par- 
ticular method  of  operation  does  not  seem  to  have  any  decisive 
bearing  on  the  result.     End-to-end   suture  and   nerve  grafting 


48       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

give  equally  good  results.  Chiray  and  Roger  are  convinced  of 
the  importance  of  postoperative  treatment,  particularly  the  use 
of  a  prosthesis  and  of  the  local  ionization  of  potassium  iodid. 
Dr.  Albert  Frouin,  who  has  done  considerable  research  work  on 
the  suture  of  nerves  after  complete  section,  reported  to  the  So- 
ciete  de  Biologic  the  results  he  obtained.  He  makes  an  immediate 
suture,  using  silk  floss  instead  of  catgut  for  suture  material,  and 
the  finest  needles  obtainable  so  that  he  can  suture  the  perineurium 
without  injuring  the  axis  cylinders.  Seventeen  animals  operated 
on  in  this  manner  walked  very  well  on  the  soles  of  their  feet  after 
fifteen  days. — Tlic  Journal  of  the  Am.  Med.  Asso. 


The  Blister  In  Prostatic  Enlargement  and  Irritation 
OF  THE  Bladder. 


A  short  time  since  a  man  of  about  forty  years  called  at  my  of- 
fice with  about  the  worst  case  of  bladder  irritation  and  apparent 
prostatic  enlargement  I  ever  saw,  and  as  a  result  of  a  case  of 
gonorrhea.  Night  or  day  he  did  not  have  ten  minutes  of  rest 
from  the  usual  symptoms  of  prostatic  enlargement  and  bladder 
irritation. 

At  the  time  I  was  myself  confined  to  my  room  with  a  case  of 
tonsillitis,  for  which  I  had  used  a  fly  blister,  which  I  am  in  the 
practice  of  applying  in  the  early  stage  and  with  the  view  of  abort- 
ing the  case.  The  case  of  my  patient  seemed  so  urgent  that  I  at 
once  thought  of  trying  a  blister  to  the  perineum,  notwithstanding 
the  possible  irritation  to  the  bladder  that  cantharides  might  pro- 
duce. I  gave  the  patient  a  box  of  the  fly  blister  and  instructed 
him  how  to  use  it,  urging  him  to  make  repeated  efforts  until  he 
got  a  blister  and  to  keep  it  open  by  repeated  use.  Of  course,  I 
also  gave  him  a  reasonable  supply  of  opium  and  a  good  kidney 
and  bladder  remedy.  The  case  had  been  running  two  or  three 
months  before  the  patient  came  to  me  and  had  been  treated  by 
his  home  doctor. 

He  reported  a  few  days  ago  and  seemed  about  well  and  said: 

"My  brother  said,  'How  did  Dr.  P ever  cure  you  so  quickly?" 

What  I  want  to  say  in  conclusion  is  this :    I  have  had  lots  of  ex- 


EXTRACTS  FROM  JOURNALS  49 

perience  with  cases  of  this  kind  and  have  used  the  bhster  more 
than  any  man  in  America,  I  beHeve,  and  for  various  troubles,  and 
I  am  wilhng  to  stake  my  reputation  that  I  have  made  a  discovery 
in  using  the  bhster  for  prostatic  enlargement. 

I  suggest  that  a  splendid  thing  to  do  also  in  such  cases  is  to 
follow  the  blister  with  an  application  of  antiphlogistine  or  some- 
thing similar. — Medical  Brief. 


MBDICAL 


M.arfan's  Epigastric  Puncture  in  Pericarditis 
WITH  Effusion. 


Among  recent  discoveries  bearing  on  pericarditis  with  effusion 
and  its  treatment  there  are  a  few  of  as  much  interest  as  Alarfan's 
epigastric  puncture.  This  operation  is  both  exploratory  and  cura- 
tive. All  who  have  tried  it  bear  testimony  to  its  innocuousness 
and  its  value  especially  in  tuberculosis  and  renal  pericarditis.  It 
deserves  to  be  systematically  employed  in  rheumatic  pericarditis 
in  which  we  should  hardly  venture  to  employ  Dieulafoy's  method. 

As  to  the  technique  of  the  operation  here  are  the  details  given 
by  Dr.  P.  Lereboulet.  The  patient  should  be  half  sitting  up  in 
bed,  the  epigastric  region  uncovered  and  disinfected.  Take  a 
small  trocar  belonging  to  a  Potain  apparatus  attached  to  the  as- 
pirator, or  a  stout  lumbar  puncture  needle,  not  too  pliable,  fixed 
to  a  10  or  20  cc.  glass  syringe.  The  site  of  the  puncture  is  imme- 
diately below  the  xyphoid  appendix  in  the  middle  line,  the  needle 
being  then  directed  obliquely  from  below  upwards  by  depressing 
the  handle  towards  the  abdominal  wall  as  we  proceed  inwards  in 
order  to  bring  the  needle  in  proximity  to  the  posterior  surface  of 
the  xyphoid  appendix  and  sternum,  in  fact  as  if  we  wished  to 
scrape  that  surface.  Having  penetrated  to  a  depth  of  4  centime- 
tres in  the  child  of  6  in  the  adult  the  needle  will  have  entered  the 
pericardial  sac. 

There  are  two  formal  contraindications  z'ic  excessive  abdomi- 
nal tympanites  preventing  our  taking  the  xyphoid  appendix  as 


60       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

our  guide  and  the  peculiar  deformity  of  the  thorax  known  as  fun- 
nel-shaped or  infundibular  thorax. 

Should  there  be  any  error  of  diagnosis  the  puncture  will  reveal 
the  fact  and  this  without  any  untoward  consequences.  If  there 
be  fluid  it  enables  it  to  be  withdrawn  without  the  least  risk  to  the 
patient.  In  suppurative  pericarditis  it  ought,  however,  only  to 
serve  the  purpose  of  ascertaining  the  nature  of  the  fluid  because 
pericardotomy  will  have  to  be  performed  at  once.  It  might  con- 
ceivably fail  us  in  cases  of  posterior  pericarditis  as  described  by 
Cassart  in  which  the  fluid  is  shut  oft"  and  encysted  at  the  back  of 
the  heart. — Le  Monde  Medical. 


Heroix  of  No  Value. 


At  a  recent  meeting  of  the  Committee  on  Drug  Addiction  of 
the  Committee  on  Social  Hygiene  of  the  National  Committee  on 
Prisons,  it  was  regularly  moved  by  Dr.  Frederick  Peterson  and 
seconded  by  Dr.  Samuel  W.  Lambert  that  it  be  resolved  that  in 
the  opinion  of  the  committee,  the  drug  heroin  is  of  no  real  value 
in  the  practice  of  medicine  and  that  its  place  may  be  better  taken 
by  more  efficacious  agents  that  do  not  menace  public  welfare. 

Resolved,  That  the  committee  recommend  federal  legislation  to 
prevent  the  importation,  manufacture  and  sale  of  heroin  in  the 
United  States. — Neiv  Orleans  Med.  and  Sur^.  Journal. 


Pellagra. 


Sambon  has  maintained  for  eleven  years  that  pellagra  is  prob- 
ably an  infectious  disease,  possibly  the  work  of  some  protozoon, 
which  is  transmitted  by  the  sting  of  some  winged  insect.  Recently 
he  has  studied  pellagra  in  Europe,  the  United  States  and  the  An- 
tilles, and  he  has  established  its  presence  in  the  British  Isles,  in 
British  Guiana,  and  in  several  parts  of  France.  '  He  has  noted  the 
prevalence  of  pellagra  in  quite  young  children  in  the  endemic  foci, 
also  the  great  importance  of  the  disease  as  a  cause  of  insanity. 
He  says  that  the  history  of  pellagra  as  he  traces  it  through  the 


EXTRACTS  FROM  JOURNALS  61 

centuries  and  in  different  countries  shows  that  it  occurs  in  cer- 
tain regions,  like  sleeping  sickness,  and  that  those  endemic  foci 
remain  permanent.  Outside  of  the  endemic  foci  the  disease  can 
neither  be  contracted  nor  transmitted.  No  instance  is  known,  he 
affirms,  of  transmission  of  the  disease  in  the  hospitals  or  asylums 
to  the  medical  or  nursing  force  or  other  inmates,  or  from  a  pel- 
lagrin to  her  nursing  infant.  In  the  endemic  foci  the  disease  is 
inevitably  contracted,  and  usually  within  the  first  year.  The  pe- 
riod of  incubation  may  be  less  than  two  weeks.  The  youngest  pel- 
lagrin he  has  encountered  was  a  three  months  babe.  The  recur- 
rences of  the  disease  are  like  those  of  malaria;  the  flare-up  may 
occur  in  March  while  the  new  cases  develop  later,  in  April,  May 
or  June.  In  conclusion  Sambon  remarks  that  pellagra  was  known 
in  Europe  long  before  the  introduction  of  corn  from  America,  and 
the  geographic  distribution  of  the  cultivation  or  consumption  of 
com  does  not  coincide  with  the  distribution  of  pellagra,  while 
prophylaxis  based  on  the  corn  theory  has  proved  futile. — The 
Journal  of  the  Am.  Med.  Asso. 


Treatment  of  V'incent's  Angina  and  Ulceromem- 
branous Stomatitis. 


Ramond  states  that  in  his  division  Vincent's  angina  is  increas- 
ing while  diphtheria  is  diminishing.  The  stomatitis  is  frequently 
associated  with  the  first  named,  while  the  two  also  occur  isolated. 
Lack  of  mouth  hygiene  seems  to  be  the  efficient  cause.  The  mi- 
crobiology and  treatment  are  practically  the  same  for  each  locali- 
zation. Neo-arseno-benzol  (neosalvarsan)  is  the  best  remedy,  but 
is  too  costly,  and  something  must  be  substituted,  to  wit,  intensive 
local  treatment.  In  the  case  of  angina  all  membrane  must  be  re- 
moved mechanically,  after  which  solution  of  silver  nitrate  1-50 
is  applied.  This  application  should  be  preceded  by  a  gargle  of 
cocaine  solution  and  the  use  of  a  blunt  curette  for  removing  all 
membrane  and  sanious  detritus.  Hemorrhage  is  slight  and  con- 
trolled by  a  gargle  of  hydrogen  peroxide.  The  raw  surfaces  be- 
gin to  granulate  and  soon  cicatrize.     In  ulceromembranous  stom- 


62       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

atitis  the  curette  may  be  of  use,  but  is  not  adapted  for  gingivitis, 
and  a  hard  toothbrush  is  substituted.  The  toothbrush,  Ramond 
says,  should  be  used  for  several  days  in  succession  and  be  followed 
up  with  silver  solution. — Medical  Record. 


Hyperidrosis. 


A.  W.  Stillians,  Chicago  (Journal  A.  M.  A.,  December  30, 
1916),  says  that  treatment  heretofore  had  been  unsatisfactory 
until  it  had  been  shown  that  it  could  be  controlled  by  the  Roent- 
gen ray.  This,  however,  is  expensive  and  not  altogether  safe,  and 
he  recommends  to  the  patient  as  an  inexpensive  local  application 
a  25  per  cent  solution  of  aluminum  chlorid.  In  prescribing  this 
the  fact  that  it  is  incompatible  with  alkalies,  sulphur,  phosphorous 
and  salenium  must  be  remembered. — Northzucst  Medicine. 


Spontaneous  Pneumothorax  in  Pulmonary 
Tuberculosis. 


Bonsworfif  concludes  from  his  experience  in  nineteen  cases  of 
this  kind  that  treatment  should  aim  to  transform  the  spontan- 
eous pneumothorax  into  a  seropneumothorax  or  serothorax,  and 
then,  as  soon  as  the  fistula  has  healed,  to  aspirate  the  effusion  and 
introduce  nitrogen  in  its  place,  keeping  up  the  artificial  pneumo- 
thorax as  long  as  conditions  require.  This  method  was  applied 
in  three  of  his  cases  and  proved  completely  successful  in  two.  In 
the  third  case  the  fistula  refused  to  heal. — TJie  Journal  of  the  Am. 
Medical  Association. 


The  Treatment  of  Amoebic  Dysentery. 


In  a  second  communication  (British  Medical  Journal,  August 
24,  1912,  and  Univ.  Med.  Record,  July,  No.  402),  Prof.  Leonard 
Rogers  says  that  there  is  no  doubt  at  all  that  the  subcutaneous 
injection  of  soluble  emetine  salts  is,  in  cases  of  amoebic  dysentery 
and  hepatitis,  a  specific  remedy  more  active  perhaps  than  any  in 


EXTRACTS  FROM  JOURNALS  6« 

the  whole  range  of  medicine — not  excepting  quinine  and  salvar- 
san.  Moreover,  the  reaction  is  so  marked,  as  actually  to  be  of 
diagnostic  import.  The  most  useful  salt  is  the  hydrochloride  of 
emetine,  in  doses  of  from  gr.  >4  to  gr.  2-3  daily.  The  effects  are 
so  surprising  as  to  render  mere  verbal  description  feeble,  and 
offer  a  curious  commentary  on  the  therapeutics  of  those  who 
have  attempted  to  show  good  results  in  such  cases  from  the  ad- 
ministration of  ipecacuanha  sine  emetine.  In  a  later  note  Rogers 
says  that  emetine  is  almost  equally  efficacious  when  given  by 
mouth. — Pacific  Medical  Journal. 


Sympathy. 


A  doctor  should  not  be  harsh,  hard-hearted  and  unsympathetic! 
He  should  be  kindly,  gentle  and  sympathetic.  It  is  the  most 
grateful  thing  in  the  world,  where  there  is  a  life  hanging  by  a 
slender  thread.  Many  times  where  there  is  mental  anguish  and 
heart-breaking  anxiety,  the  presence  of  the  good  physician  is  ap- 
preciated beyond  expression.  If  he  can  no  longer  minister  to  the 
dying,  he  can  at  least  be  a  solace  to  the  living.  There  seems  to 
be  something  heartless  for  a  physician  to  pronounce  a  case  hope- 
less and  abruptly  leave  the  grieving  family  to  face  the  approach- 
ing death  without  the  closing  ministrations  of  that  physician. 
Stay  by  them  to  the  end.     It  will  pay ! — Charlotte  Med.  Journal. 


The  Oculocardiac  Reflex  In  Hypothyroidism. 


Petzetakis  studied  myxedematous  idiots,  ordinary  cases  of  my- 
xedema, and  subjects  with  hypothyroidism  in  connection  with  the 
oculocardiac  reflex  as  controlled  by  auscultation  and  the  sphyg- 
mograph.  It  was  possible  in  some  of  these  subjects  to  arrest  the 
heart  beat  for  as  long  as  15  seconds,  during  which  the  subject 
became  as  dead — pale  and  unconscious.  When  the  heart  resumed 
action  it  beat  25  to  30  times  the  first  minute.  The  normal  be- 
havior of  this  reflex  was  therefore  greatly  augmented.  It  is  be- 
lieved that  the  reduction  below  normal  of  thyroid  substance  in 


54       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

the  blood  depressed  the  sympathetic  and  thus  allowed  the  vagiis 
to  overact — in  other  words,  these  subjects  were  rendered  vago- 
tonic. In  hyperthyroidism  and  opposite  effect  can  not  be  obtained 
in  the  same  degree — in  fact,  the  heart  was  slowed  as  well  as  ac- 
celerated. If  hyperthyroid  subjects  are  given  thyroid  substance 
the  results  are  likewise  inconclusive. — Medical  Record. 


OBSTETRICAL. 


Hematocolpos  in  Woman  of  Seventy-Four. 


In  a  woman  of  74  who  had  menstn.iated  normally  until  thirty- 
five  years  previously,  severe  pain,  pointing  to  obstruction  of  the 
urinary  flow,  led  to  the  detection  of  a  large  fluctuating  tumor 
which  filled  the  entire  pelvis  and  extended  upward  almost  to  the 
umbilicus.  The  vagina  was  occluded  by  senile  atresia.  Laparot- 
omy in  spinal  anesthesia  revealed  the  tumor  to  be  an  enormous 
hematometra  and  hematocolpos  with  bilateral  hematosalpinx. 
Panhysterectomy  was  performed  successfully  by  Gellhorn,  and 
the  tumor,  which  was  connected  with  the  vagina  only  by  loose  con- 
nective tissue,  was  removed  unopened.  Convalescence  was  undis- 
turbed; the  patient  left  the  bed  on  the  twelfth  day  after  operation 
but  succumbod  to  an  embolism  on  the  fifteenth  day.  The  cause  of 
bleeding  into  the  occluded  genital  tract  was  an  adeno-carcinoma 
of  the  body  of  the  uterus. — The  Journal  of  the  Am.  Med.  Asso. 


The  Use  of  Pituitary  Extract  in  Post- Abortion 
Curettage. 


In  an  editorial  note  in  the  Medical  Record  of  December  2,  1916, 
mention  was  made  of  this  use  of  pituitrin,  and  the  statement  was 
ventured  that  it  was  first  proposed  by  a  writer  in  Surgery,  Gyne- 
cology and  Obstetrics  for  September,  1916.  We  have  learned  that 
this  was  an  error,  as  Dr.  Jacob  L.  Bubis,  of  Cleveland,  in  a  paper 
read  before  the  Gynecological  Section  of  the  New  York  Academy 


EXTRACTS  FROM  JOURNALS  55 

of  Medicine  on  Xovember  23,  1915  (American  Journal  of  Ob- 
stetrics, No.  4,  1916),  reported  three  cases  in  which  this  measure 
was  resorted  to  with  success.  The  advantages  of  giving  pituitary 
extract  in  these  cases  he  summarized  as  follows :  1 1 )  Preliminary 
packing  of  the  cervix  and  vagina  to  induce  softening  of  the  cer- 
vix and  stimulate  uterine  contractions  is  usually  unnecessary.  (2) 
No  packing  is  placed  in  the  cervix  or  vagina  after  emptying  the 
uterus.  (3)  The  injection  of  pituitrin  is  given  after  the  cervix 
has  been  dilated  while  the  patient  is  under  an  anesthetic.  (4) 
Very  little  blood  is  lost  while  removing  the  placenta  piecemeal. 
(4)  The  uterine  cavity  decreases  in  size  as  rapidly  as  its  contents 
are  removed.  (6)  N-e  hot  irrigations  are  necessary.  (7)  The 
total  operation  takes  only  a  few  minutes. — Medical  Record. 


Progress  ix  Our  Knowledge  of  Ov.xrian  Substance 
Therapy. 


The  absence  of  a  definite  physical  action  in  the  genital  gland 
extract  (in  contrast  with  the  thyroid,  hypophysis  and  adrenals) 
will  doubtless  cause  scepticism  regarding  the  therapeutic  value  of 
these  bodies.  Bucura  in  the  Centralblatt  fur  Gynakologic 
October  14,  blames  this  scepticism  in  part  upon  poor  ovarian  ex- 
tracts, the  manufacture  of  which  in  Germany  is  without  State 
control.  The  substance  again  is  by  no  means  always  identical  when 
prescribed.  Finally  much  may  depend  in  practice  on  the  animal 
which  supplies  the  organs.  We  know  nothing  of  a  pure  ovarian 
hormone,  and  if  such  exists  it  has  no  connection  with  the  corpus 
luteum.  At  puberty  not  the  latter  but  the  original  inner  secre- 
tion, acting  in  greatly  increased  production,  is  responsible  for  the 
characteristic  changes  in  the  female  organisms.  For  biological 
reasons  ovarian  extracts  should  come  from  the  sheep  or  pig,  pref- 
erably the  latter. 

In  the  natural  and  artificial  climacteric  a  good  preparation 
should  be  given  in  increasing  dose  until  all  unpleasant  symptoms 
disappear,  which  may  require  from  one  to  three  years.  The  ex- 
tract had  best  be  given  first  over  a  period  of  3  to  8  weeks,  after 


56       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

which  it  is  discontinued  for  one  week,  to  be  resumed  ag"ain  for 
4  to  6  weeks,  etc.  Eventually  one  week  in  each  month  represents 
the  period  of  exhibition.  Apparently  a  high  blood  pressure  may 
be  brought  down  by  the  treatment.  Aside  from  the  climacteric 
the  indication  for  ovarian  extract  are  ver}^  numerous ;  in  general, 
whenever  the  function  of  the  ovary  is  defective.  Hence,  it  may 
be  tried  out  in  many  obscure  conditions.  Thus  far  the  only  known 
contraindication  is  tuberculosis. 

In  opposition  to  Bucura's  views  as  based  on  clinical  experience 
numerous  experimenters  regard  the  corpus  luteum  as  having 
highly  specialized  properties.  It  has  even  been  claimed  that  it  is 
able  to  arrest  the  development  of  the  testicle  in  young  animals. 
Novak,  in  an  article  on  the  functions  of  the  corpus  luteum  (Cen- 
tralblatt  fur  GynakoXogie,  October  28),  agrees  with  Bucura  that 
the  difference  between  the  secretion  of  the  corpus  and  that  of  the 
follicle  is  merely  one  of  degree — Medical  Record. 


Zixc  Chlorid  IX  Uterine  Hemorrhage,  Particularly  When 
Caused  by  Uterine  Myomas  and  Metro-Endometritis. 


Dr.  H.  J.  Boldt,  New  York:  I  do  not  approve  of  the  removal 
of  the  uterus  for  bleeding  if  it  is  not  the  seat  of  a  neoplasm.  Zinc 
chlorid  is  used  in  all  instances  of  severe  bleeding,  whether  due  to 
metro-endometritis  or  simple  endo-metritis,  but  particularly  when 
caused  by  interstitial  myomas  of  small  size.  In  large  tumors, 
especially  of  the  uterus,  it  is  more  desirable  to  extirpate.  I  use  a 
50  per  cent  solution  of  zinc  chlorid  more  frequently  than  weaker 
solutions.  Care  must  be  taken  to  avoid  having  the  medicament 
come  in  contact  with  the  cervical  mucosa  lest  a  stricture  result. 
In  several  instances  of  very  profuse  bleeding  from  interstitial 
myomas,  some  measuring  about  6  inches  in  diameter,  in  women 
past  40  years  of  age,  I  have  seen  complete  amenorrhea  established 
after  using  twelve,  or  even  a  less  number  of  zinc  chlorid  applica- 
tions. While  the  tumore  do  not  decrease  in  size,  the  health  of  the 
patients  improves  as  the  result  of  amenorrhea.  There  must  be  no 
oozin?  of  blood   from  the  endometrium  when  the  intra-uterine 


EXTRACTS  FROM  JOURNALS  67 

applications  are  made;  the  uterine  cavity  must  be  dry.  If  it  is  not, 
it  may  be  prepared  with  an  intra-uterine  tampon  of  styptic  gauze. 
— The  Journal  of  the  Amer.  Med.  Asso. 


Ectopic  Pregnancy, 


The  conclusions  reached  by  Oastler  from  observation  of  these 
cases  would  seem  to  be  that  all  subacute  ectopic  pregnancies 
should  be  operated  on  at  once,  removing  from  the  abdomen  the 
tube  affected,  the  fetus_^  placenta,  membranes  and  blood.  All 
acute  cases  should  be  operated  on  at  once  except  cases  in  extre- 
mis. In  these  cases  it  would  seem  advisable  to  wait,  watching 
the  patient  very  carefully.  If  no  improvement  occurs  in  a  very 
short  time,  operate.  Two  patients  of  this  series  bled  to  death. 
The  ovarian  artery  had  ruptured  in  both.  One  was  an  interstitial 
pregnancy.  As  there  is  no  doubt,  therefore,  that  patients  can 
bleed  to  death,  operation  must  not  be  delayed  too  long  in  waiting 
for  a  reaction  in  these  extreme  cases.  The  abdominal  route  was 
chosen  in  all  these  cases  and  it  is  undoubtedly  the  only  safe  pro- 
cedure to  follow.  Insasmuch  as  there  were  no  cases  extending  to 
the  viability  of  the  child  in  the  series  there  will  be  no  discussion  of 
the  treatment  in  this  condition. — The  Journal  of  the  American 
Medical  Association. 


58       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


lEittunal 


Publisher's  Notice — The  Journal  is  published  in  monthly  numbers  of  48  pa^es 
at  $1.00  a  year,  to  be  always  paid  in  advance. 

All  bills  for  advertisements  to  be  paid  quarterly,  after  the  first  insertion  of  the 
quarter. 

Business  communications,  remittances  by  mail,  either  by  money  order,  draft,  or 
reitlstered  letter,  should  be  addressed  to  the  Business  manager,  C.  S.  BriesTS.  M.  D. 
corner  Summer  and  Union  Streets,  Nashville,  Tenn. 

All  communications  for  the  Journal,  books  for  review,  exchanges,  etc.,  should  be 
addressed  to  the  Editor. 


Legislation. 


We  have  at  hand  a  newspaper  clipping  stating  that  a  bill  will 
be  presented  to  the  legislature  of  South  Dakota  to  make  it  illegal 
to  remove  a  normal  appendix ;  illegal  in  that  surgeons  removing 
such  an  organ  can  not  make  the  patient  pay.  It  is  aimed  at  un- 
skillful and  unscrupulous  surgeons,  and  the  citizens  of  South 
Dakota  will  be  protected  satisfactorily,  since  all  appendices,  after 
removal,  must  be  sent  to  the  state  laboratory  for  examination. 

We  would  like  to  suggest  that  the  author  of  such  a  bill  be  sent 
for  examination,  too ;  not  to  the  laboratory  but  to  the  observation 
ward  of  the  state  asylum. 

This  bill  is  but  one  of  the  many  that  are  annually  proposed  to 
the  legislators  of  the  country,  which  show  that  some  steps  should 
be  taken  to  regulate  the  personnel  of  our  state  legislatures. 

However  the  bill  may  be  intended,  it  is  certainly  a  nice  compli- 
ment to  modern  surgery,  since  it  shows  what  the  average  layman 
— and  the  author  of  this  bill  can  not  be  above  the  average — thinks 
of  the  diagnostic  ability  of  reputable  surgeons. 

Unfortunately  the  author  is  not  versed  in  microscopic  pathol- 
ogy,  to  say  nothing  of  the  fact  that  he  can  not  realize  how  close 
together  and  how  confusing  are  the  symptoms  arising  in  the  ap- 
pendix, gall  bladder,  pancreas,  kidney,  ureter.  Fallopian  tube  and 
intestines ;  and  had  he  conferred  with  some  doctor  friend  he  would 
have  learned  that  the  appendix  varies  in  length  from  almost  noth- 


EDITORIALS  69 

ing  to  nine  or  ten  inches,  and  that  one  microscopic  section  can 
show  marked  inflammation  while  an  inch  or  so  distant  the  celhi- 
lar  elements  may  appear  normal.  This  simply  means  that  the 
state  laboratory  would  have  to  examine  serial  sections  of  each 
microscopically  normal  appendix  before  the  organ  could  be  classed 
as  normal.  Furthermore,  it  would  mean  longer  delay  before  op- 
eration, since  the  physicians  of  that  state  would  not  care  to  be 
classed  with  the  unskillful,  and  the  inter\'al  operation  would  be- 
come as  rare  as  it  is  now  frequent. 

This  bill  not  only  emphasizes  the  old  saying,  "Medical  questions 
to  medical  men,"  but  also  the  growing  tendency  of  the  state  to 
regulate  the  practice  of  "medicine  far  more  than  any  other  profes- 
sion or  business.  Bills  like  the  above  should  teach  us  that  we  need 
a  Federal  Bureau  of  Health,  one  of  whose  functions  would  be  to 
pass  on  the  work  of  state  medical  bills  before  they  are  voted  on 
by  men  necessarily  ignorant  of  medicine  and  surgery ;  such  bills — 
whether  passed  or  not — should  also  emphasize  the  pressing  need 
for  lesrislative  reform  of  the  legislatures  themselves. — W.  T.  B. 


United  States  Public  Health  Service. 


"Pray,  ]\Ir.  Abernethy,  what  is  a  cure  for  gout?"  was  the  ques- 
tion of  an  indolent  and  luxurious  citizen. 

"Live  upon  sixpence  a  day,  and  earn  it,"  was  the  cogent  reply. 

John  Abernethy,  second  son  of  a  Scotch-Irish  family,  born 
April  3,  1764,  a  physician  of  rare  discernment,  a  surgeon  of  great 
skill,  a  lecturer  and  teacher  of  dramatic  magnetism,  never  said  a 
better  thing  in  his  life.  It  is  particularly  apt  in  this  country  where 
the  sin  of  overeating  is  far  more  common  than  the  sin  of  over- 
drinking. Gluttony,  always  a  fault,  is  all  the  more  glaring  in  a 
land  where  a  plentiful  food  supply  permits  it  to  be  more  general. 
The  sallow,  fat  cheeks,  the  aching  joints  and  irascible  temper  of 
the  prosperous  over- fed  are  far  too  common.  Abernethy  said  to 
one  such,  the  Duke  of  York,  by  the  way,  "Cut  off  the  supplies  as 
the  Duke  of  Wellington  did  in  his  campaigns,  and  the  enemy  will 
leave  the  citadel." 


60       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Diet,  however,  is  a  really  serious  matter  and  many  people  suf- 
fer as  much  from  dietary  eccentricities  and  food  fads  as  from 
actual  disease.  The  average  individual  can  eat  good,  plain,  whole- 
some food  in  moderation  all  his  life  without  ever  being  aware 
that  he  has  a  digestive  apparatus.  Starvation  to  cure  a  fancied 
ailment  or  to  reduce  an  expansive  waist  line  has  shortened  many 
lives,  just  as  indiscretion  in  the  opposite  direction.  Certain  dis- 
eases do  require  a  particular  diet,  but  this  should  be  chosen  by  a 
physician  of  skill  and  not  self-prescribed.  The  self-prescriber 
often  has  a  fool  for  a  patient. 

Abemethy  was  married  on  January  9,  1800,  to  a  lady  whom  he 
met  at  the  house  of  a  patient.  A  brief  courtship  was  followed  by 
a  proposal  by  letter,  giving  the  lady  a  fortnight  in  which  to  make 
up  her  mind  and  deprecating  any  "dangling."  He  was  not  as  tem- 
perate with  regard  to  work  as  he  was  to  food.  He  did  not  even 
interrupt  his  lectures  for  his  wedding,  and  died  at  the  age  of  67, 
completely  worn  out,  a  victim  of  his  gluttony  for  work. 


Editor  The  Journal  of  Medicine  and  Surgery,  Nashville,  Tenn.: 
Dear  Sir— At  last  the  time  has  arrived  when  the  fight  is  no 
longer  between  the  Anti-Saloon  League  and  the  "liquor  interests." 
It  is  now  a  fight  between  the  forces  of  intolerance  and  the  forces 
of  human  freedom — for  control  of  body,  soul  and  business. 

The  issue  is  squarely  presented  by  the  passage  of  the  Bank- 
head  bill  in  the  Senate  and  the  imminence  of  the  passage  of  it  or 
the  Randall  bill  in  the  House — both  measures  designed  to  deny 
the  use  of  the  mails  to  any  newspaper,  magazine  or  other  publica- 
tion going  into  either  prohibition  state  or  local  option  county  and 
carrying  any  advertisement  of  intoxicating  liquor  or,  it  may  be, 
of  any  medicine  containing  a  substantial  amount  of  alcohol. 

For  several  years  the  Anti-Saloon  League  has  been  trying  to 
persuade  newspapers  and  magazines  to  decline  liquor  advertising. 
With  some  of  the  publications  this  persuasion  was  effective.  With 
others  it  was  not,  and  now  comes  the  attempt  at  legislative  coer- 
cion, with  the  penitentiary  in  the  background. 


EDITORIALS  61 

The  fight  for  censorship  of  the  columns  of  the  newspapers  will 
not  stop  with  attacks  on  liquor  advertisements  or,  indeed,  with 
attempts  to  control  advertisements. 

Several  states  now  prohibit  the  manufacture  or  sale  of  cigar- 
ettes, and  it  is  inevitable  that  the  Anti-Saloon  League  will  be 
asked  by  the  W.  C.  T.  U.  to  urge  legislation  against  newspapers 
carrying  cigarette  advertisements  into  such  states. 

In  nearly  every  state  it  is  unlawful  to  carry  a  pistol — wliat  more 
logical  than  a  law  against  newspapers  carrying  advertisements  of 
these  death-dealing  weapons  into  such  states? 

After  the  advertising  "department  of  every  newspaper  and  mag- 
azine has  been  subjected  to  censorship  how  can  the  news  columns 
remain  free?  What  of  horse-racing  reports,  stock  market  quota- 
tions, Sunday  baseball  information— indeed  why  not  suppression 
of  Sunday  papers  and  of  Monday  papers  printed  in  whole  or  in 
part  on  the  Sabbath— all  bitterly  opposed  by  the  W.  C.  T.  U.  and 
the  Anti-Saloon  League  ? 

But  what  of  editorial  liberty?  If  it  be  decreed  that  the  use  of 
liquor  and  of  cigarettes  is  hurtful  alike  to  the  individual  and  to 
society  is  it  not  an  act  of  hostility  to  the  state  and  to  the  church 
for  an  editor  to  praise  an  old  wine  or  to  refer  indulgently  to  the 
"makins"  of  a  cigarette  or  to  oppose  in  any  way  the  cause  of  pro- 
hibition ? 

How  long  will  it  be,  I  wonder,  before  American  people  are 
jarred  into  the  realization  that  soon  they  must  look  to  the  Anti- 
Saloon  League  for  dictation  as  to  what  they  may  eat  or  drink,  as 
to  what  lines  of  business  they  may  engage  in,  as  to  how  they  may 
seek  political  preferment,  as  to  how  a  newspaper  may  be  edited 
and  what  form  of  advertising  it  may  carry  into  the  different 
states  ?  Very  truly  yours, 

T.   M.   GiLMORE, 

President  National  Model  License  League. 

-p  s. — Herewith  we  give  reprints  of  the  Randall  and  Bankhead 
bills  and  trust  that  after  reading  same  you  will  wire  your  protest 
to  one  or  more  Congressmen  and  also  attack  these  measures  edi- 
torially. 


62       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

An  ophthalmological  service  has  been  added  to  the  other  depart- 
ments of  Bellevue  Hospital,  New  York.  It  is  located  in  the  new 
surgical  pavilion  but  is  entirely  distinct  from  the  rest  of  the  hos- 
pital, having  its  own  operating,  examining  and  dressing  rooms,  a 
staff  of  attending  surgeons,  special  internes  and  nurses.  Its  ca- 
pacity for  the  present  will  be  fifty  beds.  The  service  is  in  charge 
of  Dr.  Charles  H.  May,  attending  surgeon,  who  will  have  as  his 
principal  assistants  Drs.  Julius  Wolff  and  John  M.  Wheeler. 


Surgeons  Elect  Officers. 


At  the  annual  meeting  of  the  Southern  Surgical  and  Gyneco- 
logical Association,  which  was  held  in  White  Sulphur  Springs, 
Va.,  December  11,  12,  13,  the  following  officers  were  elected: 
President,  Dr.  William  D.  Haggard,  Nashville ;  Vice  Presidents, 
Drs.  J.  Ernest  Stokes,  Salisbury,  N.  C,  and  Francis  R.  Hagner, 
Washington;  Secretary,  Dr.  Herbert  A.  Royster,  Raleigh,  N.  C. ; 
Treasurer,  Dr.  Legrand  Guerry,  Columbia,  S.  C,  and  member  of 
the  council,  Dr.  Thomas  S.  Cullen,  Baltimore.  The  1917  conven- 
tion will  be  held  in  St.  Augustine,  Fla. 


The  Southern  Gastrd-Enterological  Association. 


The  association  was  organized  in  Atlanta  on  November  15.  Ac- 
tive membership  in  this  society  will  be  Hmited  to  those  investiga- 
tors and  practitioners  of  the  seventeen  southern  states  who  are 
engaged  primarily  in  the  diagnosis  and  treatment  of  diseases  of 
the  digestive  system.  Regular  meetings  will  be  held  annually,  the 
next  place  of  meeting  yet  to  be  announced.  The  following  officers 
were  elected:  President,  Dr.  J.  C.  Johnson,  Atlanta;  vice  presi- 
dent. Dr.  J.  T.  Rogers,  Savannah ;  secretary-treasurer,  Dr.  Marvin 
H.  Smith,  Jacksonville,  Fla. ;  councilors,  Drs.  S.  K.  Simon,  New 
Orleans;  G.  M.  Niles,  Atlanta,  and  Seale  Harris,  Birmingham; 
committee  on  admission  and  ethics,  Drs.  Geo.  C.  Mizell,  Atlanta; 
J.  E.  Knighton,  Shreveport,  and  J.  B.  Fitts,  Atlanta. 


PUBLISHERS'  DEPARTMENT  63 


^uhliBlf]?r'B  Btpnvtmtnt 


Sluggish,  Overloaded  Bowels. 


When  the  bowels  are  sluggish  and  overloaded,  the  whole  system 
is  usually  depressed  and  deranged  by  the  retention  of  toxic  waste 
material.  Without  delay  it  becomes  necessary  to  increase  the  ac- 
tivity of  the  bowels  and  promote  regular  evacuation  of  their  con- 
tents. For  these  purposes  there  is  no  remedy  that  will  give  more 
prompt  and  satisfactory  results — with  such  freedom  from  griping 
or  after-effects  as  Prunoids.  One  to  three  at  bedtime  will  afford 
prompt  relief — without  the  usual  cathartic  discomfort — and  rap- 
idly restore  functional  regularity  of  the  bowels.  As  one  promi- 
nent physician  has  said,  '*I  use  Prunoids  because  it  regulates  as 
well  as  evacuates  the  bowels."  Samples  will  be  sent  on  request 
to  the  Sultan  Drug  Co.,  St.  Louis,  Mo. 


"Solution  of  Albuminate  of  Iron"  (Liquor  Ferri  Albuminatis, 
Flexner.)  Contains  13  per  cent  Alcohol.  Each  teaspoonful  of 
this  preparation  represents  one  grain  of  Dry  Albuminate  of  Iron 
in  permanent  solution.  Robinson-Pettet  Co.,  incorporated.  (See 
adv.  in  this  issue.) 


Obstipation  Following  Operation. 


There  are  many  theoretical  reasons  why  Interol  should  be  of 
value  to  the  post-operatively  constipated  patient.  But  the  best 
reason  is  that  it  is  of  value.  And  the  most  gratifying  thing  about 
it  is  that  in  most  cases,  while  at  first,  the  patient  may  need  as  much 
as  oz.  I  to  oz.  Iss  of  Interol  per  day,  with  time,  he  can  diminish 
the  dosage  to  as  little  as  half  an  ounce  a  day,  or  an  ounce  every 
other  day,  and  even  discontinue  Interol  for  periods  of  time.  In 
many  cases  Interol  is  the  last  resort  to  avoid  another  use  of  the 
surgeon's  knife. 


64       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Tongaline  exerts  a  manifest  action  on  the  nervous  sys- 
tem of  the  secreting  order  of  glands,  it  diminishes  the  uric  acid 
content  of  the  blood,  and  produces  a  substitutive  irritation  in 
the  region  of  the  articular  surfaces.  On  account  of  the  exagger- 
ated vasomotor  action  of  Tongaline,  the  irritation  drives  the  pois- 
onous deposits  toward  the  emunctories,  causing  a  great  secretion 
of  bile  in  the  liver,  an  abundant  diuresis  in  the  kidneys  and  a  ser- 
ous diarrhea  in  the  intestines,  while  in  the  feces  and  in  the  urine 
we  find  a  great  quantity  of  uric  acid. 

These  conditions  secure  the  attainment  of  the  desired  effect, 
which  is  to  expel  from  the  organism  all  those  agents,  the  accumu- 
lation and  retention  of  which  in  the  blood  are  the  cause  of  rheu- 
matism, neuralgia,  grippe,  gout,  nervous  headache,  malaria,  sci- 
atica, lumbago,  tonsillitis,  heavy  colds  and  excess  of  uric  acid. 


Colds  that  linger  invariably  owe  their  persistence  to  inability  of 
the  body  to  exert  sufficient  resistance  to  overcome  germ  activity. 
Recovery,  in  consequence,  is  always  largely  a  question  of  raising 
the  general  vitality  and  increasing  bodily  resisting  power.  To  ac- 
complish this,  no  remedy  at  the  command  of  the  profession  is  so 
promptly  effective  as  Gray's  Glycerine  Tonic  Comp.  Under  the 
use  of  this  dependable  restorative  and  reconstructive,  the  appetite 
is  increased,  the  digestion  improved,  the  nutritional  balance  re- 
stored, and  the  vital  resistance  so  raised  that  the  body  can  control 
infectious  processes,  and  establish  a  safe  and  satisfactory  conval- 
escence. 

In  the  treatment  of  colds,  therefore,  "Gray's"  can  be  relied  upon 
to  raise  the  defensive  forces  of  the  organism  and  fortify  against 
Sferm  attack. 


NASHVILLE  JOURNAL 

OF  

MEDICINE  AND    SURGERY 


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


Vol..  CXI.  MARCH,  1917.  No.  3 


Original  QIommuntralinnB 


NURSING  A  DRINKING  MAN. 


BY   T.   D.    CROTHERS,    M.D.,    HARTFORD,   CONN. 


Is  is  a  very  sad  statement  to  make  but  is  probably  true,  that 
one  out  of  twenty  families  in  the  country  have  some  member 
who  is  often  very  sick  from  the  excessive  use  of  spirits.  The 
physician  is  not  often  called  from  pride  and  desire  to  conceal 
what  is  thought  to  be  a  moral  weakness.  A  nurse  is  brought  in 
and  after  a  few  days  the  patient  recovers.  Some  time  in  the 
future  this  occurs  again,  and  bye  and  bye  the  physician  is  called, 
and  curious  explanations  are  given  to  friends  outside,  and  the 
physician  simply  smiles  and  says  nothing,  but  the  family  and  the 
nurse  are  keenly  aWare  of  the  trouble  and  are  always  more  or 
less  confused  and  do  not  know  what  to  do.  The  person  may 
come  home  stupid  or  garrulous  and  very  irritable,  scolding,  fault- 
finding and  unreasonable.  The  family  are  greatly  distressed  and 
a  nurse  is  called  in.  The  patient  soon  believes  that  he  is  sick, 
giving  other  reasons  than  the  use  of  spirits  as  a  cause  and  sub- 
mitting to  the  instructions  of  the  nurse.     In  a  little  while  he 


66       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

recovers  from  this  excited  condition  and  not  unfrequently  insists 
on  having  spirits  to  keep  up  his  condition.  Attempts  made  to 
limit  or  prevent  its  use  are  resented,  and  after  a  time  he  submits, 
but  most  disagreeable  scenes  occur  in  the  family.  There  are  no 
books  of  instructions  for  treating  such  persons,  even  the  physi- 
cian has  a  very  vague  idea  of  what  is  best  to  do.  If  he  is  called, 
and  the  patient's  delusions  seem  uncontrollable,  he  will  give  some 
emetic,  and  this  may  be  followed  by  prostration  and  sleep,  or  he 
may  give  some  narcotic  that  will  produce  sleep  for  a  time.  These 
persons  are  practically  poisoned.  It  may  be  from  spirits  alone 
or  excessive  eating  or  both,  in  which  the  mind  and  body  is  most 
seriously  damaged.  They  think  wrongly,  they  act  strangely,  they 
have  imperfect  control  of  their  muscles  and  their  manner  is  so 
changed  as  to  suggest  insanity.  Many  families  have  skeletons 
of  this  kind  and  they  call  on  certain  persons  to  help  them  on  such 
occasions  and  what  to  do  and  how  to  do  it,  are  most  distressing 
questions.  The  nurse  should  be  very  clear  and  decided  in  her 
work  and  under  no  circumstances  show  fear  or  timidity.  In 
extreme  cases,  called  delirium  tremens,  no  matter  how  wild 
the  delusions  are,  they  shrink  from  the  resolute,  courageous  force 
of  an  emphatic  nurse.  They  will  often  obey  a  woman  when  they 
will  oppose  the  same  thing  offered  by  a  man.  Often  their  imme- 
diate family  have  very  little  influence  and  it  requires  a  stranger 
to  break  up  and  stop  the  obsession  of  the  moment.  Very  com- 
monly the  delusion  takes  the  form  of  violent,  abusive  language, 
particularly  of  those  who  are  nearest  to  them,  with  wild  threats. 
The  more  pronounced  this  is,  the  less  likely  it  is  to  materialize. 
The  nurse  has  little  to  fear  from  wild,  boisterous  talk;  the  patient 
soon  recognizes  that  this  mode  of  expression  is  useless  and 
destroys  his  ability  to  have  his  own  way.  An  authority  of  tone 
of  voice  and  imperious,  fearless  manner  breaks  up  the  intensity 
of  his  thoughts  and  makes  him  willing  to  do  what  he  is  asked. 
A  nurse  should  never  argue  or  try  to  explain,  but  in  the  briefest 
manner  acquiesce  or  deny  the  statements  he  may  make.  She 
must  insist  that  he  carry  out  her  wishes  in  the  taking  of  medi- 
cine and  then  manage  to  have  the  proper  restraint  to  be  applied 
without  explanation.     In  extreme  cases  it  is  always  wise  to  place 


ORIGINAL  COMMUNICATIONS  67 

the  patient  in  a  hospital  or  have  him  in  some  available  room  in 
the  house,  with  sufficient  force,  if  necessary,  for  restraint.  If  the 
patient  is  to  be  under  the  exclusive  charge  of  'he  nurse,  the  con- 
dition of  poisoning  must  be  recognized  and  iiot  emetic  drinks 
of  salt  water  or  mustard  and  water  together  with  cathartics  to  be 
used  at  once.  Hot  applications  to  the  feet  and  bathing  the  head 
in  cold  water  is  very  available  and  soothing.  After  free  vomiting 
and  purging,  restoration  sets  in,  then  acid  or  alkaline  drinks  may 
be  given  very  freely.  If  the  patient  complains  of  great  prostra- 
tion, rubbing  along  the  spine  and  back  of  the  neck  will  fre- 
quently produce  sleep."  If  the  person  is  very  nervous  and  rest- 
less, a  hot  water  bath  of  the  temperature  of  98°  or  100°  should 
be  given.  This  should  be  continued  for  an  hour  at  a  time,  the 
temperature  of  the  water  being  kept  up  to  a  uniform  degree. 
To  these  baths  soda  or  salt  may  be  added  in  quantities  from 
three  to  six  pounds  for  each  tub.  This  will  depend  upon  the 
state  of  the  skin.  If  it  is  dry  and  harsh,  the  soda  in  large  quan- 
tities is  required.  If  the  skin  is  soft  and  sensitive,  small  quanti- 
ties of  salt,  three  or  four  pounds  to  the  tub,  will  be  very  useful. 
When  relaxation  has  fully  taken  place,  the  patient  must  be  put 
to  bed,  \\Tapped  up  in  blankets  and  given  a  large  dose  of  car- 
bonated waters,  enough  to  dilate  the  stomach  and  wash  out  the 
intestinal  track.  A  few  hours  later,  a  concentrated  solution  of 
hop  tea,  made  palatable  with  lemon  acid,  should  be  given  every 
two  or  three  hours  until  sleep  is  produced.  If  the  patient  com- 
plains of  hunger,  toasted  bread,  cereals,  nuts  and  small  quantities 
of  meat  m.ay  be  given.  If  the  hops  become  very  distasteful,  small 
doses  of  sulphate  of  magnesia  or  epsom  salts  flavored  with 
peppermint  or  wintergreen  wall  be  very  grateful.  This  remedy 
can  be  given  in  ten  or  fifteen-grain  doses  for  many  days,  and  is 
literally  a  most  excellent  tonic  as  well  as  a  sedative.  If  extreme 
nervousness  follow,  valerian  pills  of  the  size  of  three  or  four 
grains  may  be  given  at  night  and  early  in  the  morning.  Tea 
and  coffee  are  excellent  stimulants,  and,  as  a  rule,  are  harmless, 
but  much  depends  on  the  person.  Sometimes  a  cup  of  black 
coffee  is  invaluable,  but  its  usefulness  will  be  greatly  impaired 
by  adding  milk  and  sugar.     Tea  is  about  the  same;  cocoa  is 


68       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

much  better,  only  it  should  be  given  only  once  a  day.  Fruits 
and  fruit  juices  are  excellent  and  in  some  cases  decidedly  help- 
ful. There  may  be  a  craving  for  meats  after  the  acute  symptoms 
have  passed  by,  but  this  should  be  restricted  and  varied  with 
fish  and  fowl.  The  usual  vegetables  all  have  some  building-up 
properties.  Beer  should  not  be  used  after  spirits  are  abandoned. 
They  contain  ferments  and  the  small  quantity  of  alcohol  the}^ 
have  always  leads  up  to  stronger  spirits  after  a  time.  Sweet 
cider  is  better,  but  this  cannot  be  used  long  without  injury.  Dur- 
ing this  acute  period  of  recovery  a  wise  nurse  will  add  sugges- 
tion to  her  care.  The  patient  v^^ill  have  periods  of  remorse.  To 
intensify  these  is  not  helpful,  because  the  reaction  is  certain  to 
follow,  but  if  one  can  direct  these  remorseful  emotions  into  hope- 
ful channels  and  a  full  realization  of  the  necessity  of  a  radical 
change  and  total  abstinence  from  all  forms  of  spirits,  the  best 
results  may  be  expected.  The  patient  needs  education  more  than 
anything  else.  He  needs  to  realize  the  damage  from  spirits  and 
the  delusions  that  they  have  been  helpful  in  any  way,  broken  up. 
The  nurse  can  impress  the  patient's  mind  to  make  a  supreme 
efifort  to  change  his  opinions  and  actions  and  to  recognize  how 
far  they  are  destructive.  Signing  pledges  and  promises  may  be 
very  helpful  to  some  persons,  but  in  a  certain  proportion  of  in- 
stances, where  these  promises  are  broken,  the  condition  mentally 
is  worse.  A  certain  number  of  persons  will  willingly  carry  out 
pledges  for  total  abstinence  for  a  definite  time  and  pride  them- 
selves in  the  strength  required  to  do  this.  At  the  end  of  the 
period,  if  they  can  be  persuaded  to  renew  this,  they  acquire  new 
strength.  It  thus  happens  that  many  persons  are  held  from 
giving  way  to  their  morbid  impulses  to  take  spirits  until  their 
system  has  regained  its  sufficient  strength  to  overcome  it.  In 
other  instances  pledges  are  useless.  Patients  should  be  made  to 
understand  that  all  forms  of  alcohol  are  perilous  and  distinctly 
poisonous,  and  that  they  will  always  suffer  from  every  degree 
of  use.  One  class  of  persons  have  a  very  pronounced  love  of 
life  and  its  pleasures,  and  if  they  can  be  made  to  see  how  far 
alcohol  will  diminish  this,  an  element  of  fear  may  be  grown  and 
caution  that  will  keep  them  from  relapsing.    Another  class  have 


ORIGINAL  COMMUNICATIONS  69 

verv  little  ambitions  except  those  of  the  most  selfish  kind,  such 
as  the  acquisition  of  money  and  the  praise  of  their  fellowmen. 
Another  class  are  intensely  bound  up  with  family  ties  and  love 
of  home  and  children ;  still  another  class  are  reckless  of  the  future 
and  have  no  thoughts  except  the  enjoyment  of  the  present 
moment.  All  these  are  distinct  mentalities,  which  the  nurse  can 
recognize  and  utilize  in  the  application  of  physical  measures. 
Many  persons  consider  the  emphatic  denials  of  the  possibilities 
of  using  spirits  again,  a  most  practical  form  of  suggestion.  This 
is  not  borne  out  by  experience.  Almost  invariably  persons  who 
have  taken  the  so-called  treatments  in  institutions  and  are  told 
that  they  never  can  take  spirits  again  will  experiment  to  see 
whether  this  is  real  or  not.  If  this  experiment  is  carried  out 
under  the  direction  of  a  physician,  who  wisely  adds  some  nauseant 
to  the  spirits,  the  conviction  may  be  deepened,  but  if  it  is  at- 
tempted outside  under  favorable  circumstances,  the  delusion  that 
he  can't  drink  will  be  dissipated  at  once.  If  he  finds  the  first 
drink  not  quite  as  pleasant  as  formerly,  he  will  repeat  it  to  see 
whether  the  same  taste  exists  or  not.  This  is  sure  to  return, 
and  often  with  greater  impetuosity  than  before.  If  the  patient 
had  been  impressed  at  the  beginning  with  the  fact  that  spirits 
were  more  destructive  than  ever,  that  the  desire  and  taste  still 
remained  and  these  could  be  overcome  by  various  methods,  he 
would  rarely  make  an  experimental  test.  Giving  drugs  secretly, 
hoping  that  they  will  destroy  the  desire  for  spirits,  always  fails, 
and  a  patient  finds  out  that  he  has  been  drugged,  and  this  forms 
the  basis  for  delusions  of  persecution  in  the  future.  The  success 
of  treatment  depends  on  frankness,  not  telling  everything,  but 
making  the  patient  understand  exactly  what  is  to  be  expected. 
Persons  who  are  afraid  of  cancer,  of  kidney  disease,  of  apoplexy, 
can  be  told  clearly  to  what  extent  the  use  of  spirits  increases 
the  probability  of  these  diseases  coming  on,  and  the  suggestion 
here  often  become  a  very  powerful  factor.  The  nurse  may  be 
very  helpful  to  the  physician  in  observing  moods  and  the  inner 
hopes  and  ambitions  of  the  patient  which  the  physicians  could  not 
from  time  and  other  circumstances  obtain.  Occasionally,  such 
persons  will  insist  that  some  member  of  his  family  take  care  of 


70       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

him  when  suffering  from  drink  excesses,  and  this  member  should 
seek  the  counsel  of  a  wise  physician  to  know  how  to  conduct  his 
mental  and  physical  disorder  back  to  health  again.  In  nearly 
all  such  persons  there  is  a  self-limitation  in  which  nature  brings 
about  restoration,  and  the  best  possible  treatment  is  mental. 
Patients  themselves  soon  discover  that  purgatives  of  the  saline 
class  bring  the  quickest  relief,  or  that  Turkish  baths  or  some 
other  allied  measures  will  enable  them  to  become  sober.  For  a 
time  they  may  rely  on  these  measures,  but  sooner  or  later  they 
fail  and  something  more  is  required.  It  is  a  very  interesting 
question  which  must  be  answered  in  the  future,  as  to  how  far 
the  prohiibtion  of  alcohol  as  a  beverage  and  stopping  its  manu- 
facture and  sale  will  check  this  army  of  drink  and  drug  takers 
and  drive  them  out  of  the  community. 

A  research  foundation  has  been  organized  in  Hartford,  Conn., 
to  determine  what  causes  back  of  spirits,  force  intelligent  men 
and  women  to  use  this  drug  for  all  sorts  of  purposes.  This  will 
be  one  of  the  great  studies  of  the  future.  At  present  there  is 
so  much  confusion  of  theory  and  opinion  that  both  physicians 
and  nurses,  can  do  little -more  than  apply  the  best  possible  meas- 
ures for  the  relief  of  the  present  conditions.  It  would  be  wise 
in  every  instance  to  take  the  advice  of  a  physician  in  these  con- 
cealed cases  and  have  him  direct  the  treatment  through  the  aid 
of  intelligent  nurses.  This  could  often  be  done  with  the  great- 
est advantage,  not  only  in  these  cases,  but  in  others.  Nurses 
should  have  some  training  in  this  field  and  schools  of  nurses 
should  have  someone  to  instruct  them  what  to  do  in  the  home 
treatment  of  alcoholics  and  inebriates. 


SELECTED  ARTICLES  71 


^Attttli  Artirbfi 


THE  CARE  OF  THE  HEART  IN  PREGNANCY.- 


TASKER   HOWARD,    M.D., 

Brooklyn-New  York. 


The  subject  for  discussion  tonight  brings  up  the  question  as 
to  who  is  the  better  quahfied  to  care  for  the  pregnant  woman — 
the  obstetrician  or  the  internist.  So  far  as  the  treatment  of 
cardiac  complications  is  concerned,  I  think  it  is  evident  that  the 
obstetrician  must  frequently  feel  the  need  of  turning  to  the 
internist  for  help,  and  that  the  internist  who  tries  to  settle  all 
difficulties  without  expert  obstetrical  advice  will  often  come  to 
grief.  H  the  responsibility  had  to  be  left  with  one  man,  it  seems 
to  me  that  the  safest  adviser  would  be  a  general  practitioner  of 
sound  judgment,  who  had  not  only  confined  many  women  and 
treated  many  hearts,  but  who  was  thoroughly  familiar  with  the 
patient  herself  and  knew  from  long  observation  how  much  strain 
the  woman's  heart  could  be  depended  upon  to  bear.  During  the 
confinement  itself,  no  doubt  the  specialist  would  be  preferable. 
Hard  and  fast  rules  for  guidance  would  perhaps  nowhere  find 
more  exceptions  than  in  the  subject  under  discussion.  Each  case 
has  to  be  considered  strictly  on  its  own  merits. 

The  question  as  to  what  happens  to  the  normal  heart  in  a 
normal  pregnancy  is  still  under  discussion.  It  is  almost  the  rule 
to  find  an  enlarged  area  of  cardiac  dullness  as  pregnancy  pro- 
gresses, and  systolic  murmurs,  most  typically  at  the  base,  but  also 
at  the  apex,  are  frequently  heard.  These  physical  signs  are  in- 
terpreted by  one  school  as  being  due  merely  to  a  crowding  up  of 
the  heart  by  the  enlarging  abdomen.  Others  contend  that  a 
hypertrophy  takes   place,   and  Williams  quotes   Dreysel  to   the 


*Read  before  the  Brooklyn  Society  for  Internal  Medicine,  Nov.  24,  1916. 


72       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

effect  that  the  hearts  of  seventy-six  pregnant  and  puerperal 
women  weighed  8.8%  more  than  the  hearts  of  normal  women. 
The  fact  that  these  women  came  to  autopsy  would  seem  to  indi- 
cate that  they  could  not  be  considered  normal  pregnancies.  How- 
ever, there  is  considerable  evidence  that  the  heart  has  more  work 
to  do  during  pregnancy  than  during  the  non-pregnant  state. 
Whether  or  not  it  responds  to  hypertrophy,  the  fact  remains  that 
weak  hearts  frequently  give  way  to  the  strain  in  more  or  less 
degree.  With  or  without  local  cardiac  signs,  there  may  occur 
such  symptoms  as  dyspnoea,  an  undue  degree  of  dependent 
oedema,  or  merely  a  sense  of  fatigue  that  are  not  attributable 
to  toxemia,  and  that  respond  to  measures  directed  to  the  cir- 
culation. Digitalis,  strophanthus,  and  similar  drugs  relieve  such 
patients,  and,  of  course,  from  a  practical  standpoint,  more  im- 
portant than  any  drug  is  sufficient  rest.  It  may  be  necessary  to 
put  the  patient  to  bed,  or  mere  curtailment  of  her  exertions  may 
be  sufficient. 

In  the  management  of  chronic  heart  trouble,  more  serious  prob- 
lems arise.  In  the  first  place,  should  a  woman  suffering  from 
chronic  heart  trouble  be  allowed  to  become  pregnant?  Take, 
for  example,  what  is  usually  considered  the  most  serious  valvular 
disease  from  an  obstetrical  standpoint — mitral  stenosis.  Here  no 
general  rule  can  be  laid  down,  but  there  are  certain  principles 
which  may  be  borne  in  mind.  If  the  disease  is  of  recent  acquire- 
ment, the  heart  having  been  damaged  for  less  than  two  years, 
the  future  behavior  of  that  heart  is  still  a  matter  of  uncertainty, 
and  it  would  be  the  part  of  wisdom  to  advise  the  woman  not  to 
allow  herself  to  become  pregnant  until  it  was  shown  that  the 
heart  muscle  could  fully  compensate  for  the  valvular  defect. 
With  a  long  standing  mitral  stenosis,  if  the  patient  has  never 
suffered  from  broken  compensation,  and  there  are  present  no 
obstetrical  contraindications  (here  the  opinion  of  the  expert 
obstetrician  is  clearly  needed),  the  patient  may  be  told  that  she 
runs  but  little  added  risk  from  her  heart  trouble,  provided  that 
she  keep  in  constant  touch  with  her  adviser,  and  follows  direc- 
tions implicitly.  She  should  be  told  that  if  during  pregnancy 
there  should  occur  the  faintest  sign  of  decompensation,  it  would 


SELECTED  ARTICLES  73 

demand  immediate  attention,  that  she  might  have  to  go  to  bed 
and  perhaps  stay  there  a  long  time,  but  that  with  such  precau- 
tions there  would  be  but  slight  danger  to  herself,  and  a  very- 
fair  chance  of  a  healthy  baby,  in  the  hands  of  a  skilled  obstetri- 
cian.    Then  the  decision  may  be  left  with  the  patient. 

A  patient  with  mitral  stenosis,  who  has  previously  had  such 
symptoms  as  shortness  of  breath  or  dropsy,  should,  as  a  rule,  not 
be  allowed  to  become  pregnant. 

For  the  less  serious  cardiac  lesions  the  same  advice  would  be 
applicable.  The  involvement  of  more  than  one  valve,  or  the 
presence  of  adhesive  pericarditis  would  contraindicate  pregnancy, 
whether  or  not  the  patient  had  ever  suffered  a  break  in  com- 
pensation. 

If  pregnancy  has  already  begun  when  the  heart  patient  seeks 
advice,  the  problem  is  complicated  by  a  consideration  for  the 
life  of  the  child.  Here  again  one  must  individualize,  and  depend 
largely  upon  the  past  history  as  well  as  upon  the  present  condi- 
tion. The  various  heart  lesions  may  as  well  be  grouped  together 
in  this  consideration,  for  it  is  the  functional  capacity  of  the  heart, 
rather  than  any  anatomical  peculiarities,  that  is  of  importance. 

If  the  pregnant  woman  has  had  repeated  attacks  of  badly 
broken  compensation,  and  her  organs  are  all  in  a  condition  of 
chronic  passive  congestion,  the  chances  are  that  she  will  abort  in 
any  event,  and  I  do  not  believe  that  it  is  worth  while  to  subject 
her  to  the  very  grave  danger  of  advancing  pregnancy,  or  the 
faint  chance  of  securing  a  living  child.  In  such  a  situation,  the 
termination  of  pregnancy  should  be  advised.  It  is  sometimes 
very  difficult,  however,  to  decide  whether  a  woman  should  be 
placed  in  this  category,  or  should  be  treated  expectantly. 

A  patient  with  a  less  serious  past  history,  and  yet  with  one 
or  several  definite  breaks  in  compensation,  may  often  with  care 
be  brought  safely  through  the  pregnancy  and  confinement.  This 
means  constant  watchfulness,  adequate  and  persevering  cardiac 
therapy,  and  a  readiness  to  advise  intervention,  should  a  cardiac 
decompensation  prove  intractable  to  milder  measures. 

Given  the  mildest  type  of  valvular  lesion  in  pregnancy — that 
is  a  heart  which  in  spite  of  an  evident  anatomical  anomaly,  has 


74       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

never  shown  any  marked  limitation  in  its  field  of  response,  how 
shall  the  possessor  of  such  a  heart  be  treated  ?  During  the  early 
stages  of  pregancy,  much  like  a  normal  woman,  with  neither 
drugs  nor  rest.  Her  restrictions  should  be  placed  merely  within 
the  bounds  of  fatigue  or  breathlessness.  Of  course,  she  should 
be  carefully  watched  for  such  symptoms  as  dyspnoea,  dropsy,  or 
weakness.  Some  limitations  to  comfortable  exertion,  of  course, 
come  to  all  pregnant  wtomen,  but  when  they  appear  in  the  preg- 
nant cardiopath  they  should  be  considered  indications  for  more 
than  ordinary  restrictions  in  her  activity,  and  if  they  are  more 
marked  than  in  the  normal  woman,  she  should  be  put  to  bed. 
Digitalis  should  be  administered  if  the  response  to  rest  is  not 
satisfactorily  prompt.  If  taken  in  time  these  measures  prac- 
tically always  suffice. 

Toward  the  end  of  pregnancy,  the  heart  should  be  fortified 
with  small  doses  of  digitalis,  even  though  there  have  been  no 
signs  of  breaking  down. 

The  mortality  of  various  heart  lesions  complicating  pregnancy 
and  parturition  are  given  in  figures  of  different  observers,  which 
are  seen  to  be  most  violently  incompatible,  varying  from  .39  to 
I  per  cent  to  100  hundred  per  cent.  This  variation  is  not  sur- 
prising when  we  consider  how  utterly  different  may  be  two 
patients,  both  labeled,  say,  "mitral  stenosis."  It  is  most  mis- 
leading to  try  to  group  them.  Each  patient  constitutes  her  own 
class,  and  in  determining  what  that  class  is,  one  should  bear  in 
mind  the  fact  that,  after  all,  the  condition  of  the  heart  muscle, 
as  shown  by  its  function,  past  and  present,  is  far  more  important 
than  anything  that  can  be  learned  by  means  of  a  stethoscope. — 
Lons[  Island  Medical  Journal. 


EXTRACTS  FROM  JOURNALS  75 


£xtrart0  twm  l|omr  anlt  ForFtgn  ilnitrttala 


SURGICAL 


Acute  Syphilitic  Meningitis. 


BY  BORIS   BRONSTEIN,    M.D,^ 

Odessa,  Russia. 


Bronstein  considers  tliat  the  term  acute  syphilitic  meningitis 
should  be  more  particularly  applied  to  acute  meningeal  phenomena 
of  the  secondary  period,  sometimes  preceding,  but  more  frequently 
accompanying  the  cutaneous  manifestations  of  this  period.  The 
pathology  is  essentially  a  meningovascularitis  with  hypersecretion 
of  the  cerebrospinal  fluid.  Prodromal  symptoms,  such  as  head- 
ache and  insomnia,  may  or  may  not  occur.  Acute  syphilitic 
meningitis  at  its  height,  as  Bronstein  says  in  the  December  In- 
ternational Clinics,  presents  the  clinical  picture  of  the  tubercular 
form,  differing  from  the  latter  by  the  indistinctness  of  the  symp- 
toms, such  as  contractures  and  stiffness  of  the  neck,  and  by  the 
absence  of  any  marked  disturbance  of  the  pulse  and  respiration. 
In  the  luetic  form  fever  is  apt  to  be  absent,  and  there  may  be 
remissions  and  relapses.  Lumbar  puncture  reveals  a  consider- 
able hypertension  of  the  cerebrospinal  fluid,  albumin  in  quantity, 
and  a  marked  lymphocytosis  with  plasmozellen.  The  cere- 
brospinal fluid  may  yield  a  positive  Wassermann  even  when  the 
blood  serum  is  negative.  Other  manifestations  of  syphilis  are 
to  be  looked  for.  The  immediate  prognosis  is  rarely  fatal,  but 
the  ultimate  prognosis  should  be  reserved.  Prophylactic  treat- 
ment is  recommended  whenever  the  cerebro-spinal  fluid  shows 
a  lymphocytosis,  even  when  all  meningeal  symptoms  are  wanting. 
The  treatment  consists  in  frequently  repeated  removal  of  the 
cerebrospinal  fluid  in  considerable  amount,  combined  with  in- 
travenous injection  of  cyanide  of  mercury  and  intraspinal  injec- 
tions of  colloidal  mercurv.     Neosalvarsan  or  salvarsan  have  a 


76       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

much  more  rapid  action,    but    must    be    prudently  handled  in 
neurologic  lesions  of  syphilis. — International  Clinics. 


Carrel's  Solution. 


"Dissolve  in  a  large  bottle  140  grams  of  dry  sodium  carbonate 
in  10  liters  of  sterile  water.  Add  to  this  200  grams  of  chlorinated 
lime  (bleaching  powder),  and  shake  well.  After  half  an  hour 
siphon  off  the  clear  fluid  into  another  bottle  through  a  cotton 
plug  or  filter  paper,  and  then  add  40  grams  boric  acid  to  the 
clear  fluid." 

This  solution  is  simply  a  solution  of  boric  acid  in  solution  of 
chlorinated  soda  (Labarraque's  solution)  and  water.  It  can  be 
made  much  more  expeditiously  as  follows : 

Solution  of  Chlorinated  Soda 

(U.  S.  P.  IX.)-. 200  Gm. 

Sterile  Water 800  mils 

Boric  Acid  4  Gm. 

Dissolve.  Keep  in  well-stoppered  bottles,  in  a  cool  place,  pro- 
tected from  the  light. — Journal  American  Pharmaceutical  Assn. 


An  Improved  Substitute  for  Iodized  Catgut  Sutures. 


Watson  {Surgery,  Gynecology  and  Obstetrics,  November, 
1916)  has  shown  in  a  previous  communication  that  a  dotible  salt 
of  iodine  possessed  marked  advantages  over  iodine  for  the  im- 
pregnation of  catgut  sutures. 

Potassium  mercuric  iodide  in  water  and  alcoholic  solutions 
possessed  more  than  ten  times  the  germicidal  efficiency  of  iodine. 

Sutures  impregnated  with  this  double  salt  have  a  tensile 
strength  6.5  per  cent  greater  than  plain  sutures,  and  16.5  per 
cent  greater  than  iodized  sutures. 

Sutures  impregnated  with  the  double  salt,  when  sealed  in  tubes 
containing  a  suitable  storing  medium,  show  no  deterioration  when 
the  tubes  are  subjected  to  boiling  water. 


EXTRACTS  FROM  JOURNALS  77 

The  substitution  of  potassium  mercuric  iodide  for  iodine 
seemed  to  constitute  such  a  distinct  improvement  in  the  prepara- 
tion of  antiseptic  sutures  that  it  was  deemed  desirable  to  develop 
a  method  for  thus  impregnating  suture  materials,  and  then  to 
subject  such  products  to  exhaustive  bacteriological  tests.  The 
experiments  reported  were  planned  to  determine  the  efficacy  of 
the  procedure  in  producing  sterile  sutures,  and  the  degree  of 
antiseptic  or  germicidal  powers  imparted  to  such  sutures  by  their 
impregnation  with  potassium  mercuric  iodide. 

To  this  end,  therefore,  raw,  dehydrated  catgut  sutures  were 
treated  with  an  alcoholic  solution  of  this  salt,  placed  in  tubes 
with  various  storing  flui<ls,  and  the  tubes  sealed.  Heat  steriliza- 
tion was  omitted  in  order  to  make  the  conditions  of  the  test  more 
exacting.  All  tests  were  controlled  with  samples  of  plain, 
chromic,  and  iodized  catgut  from  several  reliable  manufacturers. 

In  conclusion  the  author  states  that  potassium  mercuric  iodide 
is  an  improvement  over  iodine  for  the  impregnation  of  suture 
materials  in  so  far  as  their  physical  properties  are  concerned. 

Sutures  impregnated  with  potassium  mercuric  iodide  possess 
a  decidedly  greater  inhibiting  power  on  the  growth  of  bacteria 
than  do  sutures  impregnated  in  the  usual  way  with  iodine. 

The  inhibiting  action  of  potassium  mercuric  iodide  sutures  is 
a  germicidal  one. — TJie  Therapeutic  Gazette. 


Improved  Tourniquet. 


Sehrt  presents  arguments  to  show  that  collaterals  develop  bet- 
ter after  ligation  of  an  artery  when  the  vein  is  ligated,  too.  Also 
that  the  tendency  to  gangrene  is  reduced  when  the  venous  blood 
is  thus  kept  in  the  limb.  He  states  that  gangrene  developed  in 
24.4  pr  cent  of  the  legs  in  which  the  artery  was  ligated  alone 
but  only  in  9  per  cent  wihen  both  artery  and  vein  were  ligated. 
In  the  arm,  there  was  gangrene  in  7.8  per  cent  with  ligation  of 
the  artery  alone  and  o  per  cent  when  artery  and  vein  were  both 
ligated.  He  ascribes  the  better  outcome  in  the  arm  to  the  fact 
that  the  arm  offers  a  much  more  extensive   reservoir  for  the 


78       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

venous  blood  than  the  leg.  He  gives  illustrations  of  a  kind  of 
clamp  with  which  it  is  possible  to  shut  off  the  blood  flow  in  the 
femoral  or  other  main  artery  by  compressing  this  artery,  as  a 
projecting  part  of  the  clamp  compresses  the  artery  alone,  while 
the  rest  of  the  limb  or  abdomen  is  left  practically  untouched. — 
The  Journal  of  the  American  Medical  Association. 


MEDICAL 


Chronic  Duodenal  Indigestion  in  Children. 


BY    JOHN    FOOTE,    M.D., 

Washinsfton,  D.  C. 


This  condition  is  said  to  occur  most  frequently  in  children 
after  the  first  year,  and  especially  in  those  who  have  suffered 
from  dietetic  errors,  usually  with  antecedent  contagious  diseases, 
or  from  prolonged  intestinal  infections,  and  this  is  fully  covered 
by  Foots  in  the  December  International  Clinics.  This  form  of 
indigestion  seems  to  be  accompanied  by  deficiency  or  pancreatic 
ferments,  especially  lipase.  A  mild  duodenitis,  which  either 
passes  up  the  pancreatic  duct,  or  diminished  hormone  formation, 
seems  responsible  for  the  condition.  Diminished  bile  production 
may  also  be  a  factor.  Anemia,  loss  of  weight  and  mental  under- 
development occur.  Large  pendulous  abdomens  are  common. 
Bottle  feeding  has  been  employed.  Fever  may  be  encountered, 
vomiting  almost  never.  The  number  of  daily  stools  varies  from 
three  to  twelve.  They  are  thin,  contain  some  mucus  and  flakes 
of  whitish  material  and  have  a  very  foul  odor.  They  give  an 
acid  reaction  and  miscroscopically  contain  not  only  large  quanti- 
ties of  fat  soaps,  but  also  a  considerable  amount  of  neutral  fat, 
but  rarely  starch  granules.  It  is  to  be  differentiated  from  mesen- 
teric tuberculosis  and  acute  duodenal  indigestion.  The  treatment 
consists  in  reducing  the  food  elements  which  have  proven  in- 
digestible, namely,  the  fat,  and  stimulating  enzyme  production  by 
the  administration  of  hydrochloric  acid  and  pancreatic  ferments. 


EXTRACTS  FROM  JOURNALS  79 

Tropical  Diseases  and  Public  Health. 


Pellagra.  F.  R.  Newman  (Xezv  York  Medical  Journal).  In 
the  early  stages  of  pellagra  the  symptoms  are  indefinite  and  mis- 
leading, but  as  the  disease  advances  they  become  more  pro- 
nounced. After  careful  clinical  observation  of  several  cases  the 
author  feels  confident  that  the  majority  will  be  benefited  by  the 
following  treatment :  First,  complete  isolation.  He  regards  the 
disease  as  communicative  and  would  have  patients  confined  in 
well-ventilated,  darkened  rooms  with  enameled  furniture,  includ- 
ing bed,  chair  and  table_.  Doors  and  windows  screened.  Mop 
the  floor  daily  with  a  strong  solution  of  creolin.  Sterilize  all 
utensils,  the  urine,  stools  and  sputum  with  chloride  of  lime. 
Control  cerebro-spinal  symptoms  with  bromides,  chloral  or  gelse- 
mium.  For  the  persistent  conjunctivitis  and  photophobia  use 
boric  acid,  sodium  chloride  and  rose  water.  Spray  nose  and 
throat  often  with  weak  solution  of  eucalyptol.  Sponge  skin 
lesions  with  permanganate  of  potash,  i  :iooo.  If  pus  is  present 
peroxide  is  useful.  For  the  eruption  he  uses  an  ointment  of 
tannic  acid,  sulphur,  ichthyol  and  wool  fat.  Bathing  in  a  strong 
solution  of  sodium  chloride  night  and  morning  will  relieve  the 
persistent  burning  and  itching  of  the  hands  and  feet. — Medical 
Pro  o-ress. 


Albuminous  Ukine. 


Does  albuminous  urine  always  indicate  Bright's  disease?  Is 
Bright's  disease,  when  present,  always  accompanied  by  albuminous 
urine  ?    To  both  of  the  queries,  the  answer  is  No ! 

It  is  certain  that  some  articles  of  food  will  cause  some  albumin 
in  the  urine.  Osier  and  Bartholow  both  assert  that  albumin  in 
the  urine  is  transitory,  and  connot  be  a  proof  of  Bright's  disease, 
provided  there  are  no  casts  to  indicate  advanced  kidney  involve- 
ment. Albumin  is  present  in  various  diseases ;  and  yet  not  pre- 
ceding diseased  kidneys.  Albumin  was  found  in  a  case  of 
'mollities  ossiiim!" 


80       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

The  excessive  use  of  too  exclusively  albuminous  diet,  such  as 
egg-s,  has  shown  albumin  in  the  urine.  Any  serious  interference 
with  the  circulation,  such  as  congestion,  will  show  albuminous 
urine.  It  was  found  that  the  inhalation  of  'arsenuated  hydrogen 
and  carbonic  acid  caused  the  urine  to  be  albuminous.  Albumin 
wull  be  slight,  and  temporary,  in  exceptional  cases,  apart  from 
dietetic  errors.  It  is  present  in  scarlet  fever,  typhoid  fever, 
ague,  diphtheria,  pneumonia,  peritonitis,  traumatism,  and  acute 
articular  rheumatism.  It  is  also  present  in  heart  disease,  ab- 
dominal tumors,  cirrhosis,  scurvy,  pyemia,  gangrene,  and  jaun- 
dice.    Persons  suffering  from  plumbism  show  it. 

Finally,  it  must  be  carefully  determined  whether  it  is  tem- 
porary, or  persistent;  or  whether  it  is  an  evidence  of  renal  dis- 
ease!— Charlotte  Medical  Journal. 


The  Oculocardiac  Reflex  With  Thyroid  Insufficiency. 


Petzetakis  reports  that  in  six  persons  with  myxedema  of  vary- 
ing degrees  of  intensity  the  reflex  phenomena  from  pressure  on 
the  eyeball  were  enormously  intensified  over  what  is  observed  in 
normal  persons.  The  hypothyroidism  leaves  the  sympathetic 
without  the  normal  stimulation  from  the  thyroid.  As  a  conse- 
quence, the  antagonist  nervous  system  gets  the  upper  hand,  and 
vagotony  results.  He  has  induced  a  similar  condition  in  dogs 
by  nerve  sections.  Under  thyroid  treatment  in  one  of  his  cases 
the  lost  balance  was  restored,  and  the  oculocardiac  reflex  after 
a  fortnight  was  about  the  same  as  in  normal  conditions.  In  two 
of  the  cases  even  light  pressure  on  the  eye  for  only  two  or  three 
seconds  arrested  the  heart's  action  for  seven,  eight,  ten  and  fif- 
teen seconds.  Not  a  sound  could  be  heard  from  the  heart  during 
this  interval,  even  on  ausculation.  The  young  man  in  one  case 
grew  pale,  stopped  breathing  and  lost  consciousness,  but  the 
pulse  gradually  resumed  its  course,  and  became  quite  normal  by 
the  end  of  the  second  minute.  It  was  the  general  impression 
that  if  the  compression  had  been  kept  up  a  few  seconds  longer 
the  syncope  would  have  been  definite.    In  this  case,  under  thyroid 


ORIGINAL  COMMUNICATIONS  81 

treatment  compression  of  the  eyeball  no  longer  induced  syncope; 
it  merely  retarded  the  pulse  to  20  or  25  beats  per  minute. — The 
Journal  of  the  American  Medical  Association. 


OBSTETRICAL 


Twilight  Sleep  in  Obstetrics. 

1.  That  scopolamine  and  morphine  injections  in  the  majority 
of  cases  diminish  the  pain  of  labor. 

2.  That  in  about  one-third  of  the  cases  amnesia  is  complete. 

3.  That  in  a  small  proportion  of  the  case  active  delirium  is 
produced  by  the  drug. 

4.  That  labor  is  prolonged. 

5.  That  the  loss  of  blood  in  the  third  stage  is  increased,  but 
tliat  severe  bleeding  is  not  common. 

6.  That  no  ill  effects  are  produced  in  the  mother. 

7.  That  the  danger  to  the  child  is  undoubtedly  increased. 

8.  That  the  dangers  are  lessened  by  constant  and  careful  super- 
vision. 

9.  That  the  treatment  should  not  be  undertaken  unless  the 
patient's  surroundings  are  favorable,  unless  the  obstetrician  is 
prepared  to  remain  with  his  patient  from  the  first  injection  until 
labor  is  completed,  and  unless  skilled  help  is  readily  available, 
should  operative  interference  become  necessary. — The  Thera- 
peutic Gazette. 


Conservative  Treatment  of  Eclampsia. 


Of  thirty-five  cases  of  convulsive  toxemia,  thirty-three  mothers 
were  discharged  well,  fifteen  children  were  born  alive  and  were 
discharged  well,  fourteen  children  were  stillborn  and  six  childrn 
died  within  a  few  hours  after  birth.  This  leaves  a  mortality  in 
the  series  of  8.6  per  cent  and  a  stillbirth  mortality  of  40  per  cent. 
All  of  these  cases  were  true  convulsive  toxemias,  having  had  one 
or  more  convulsions  before  admissioin,  and  all  were  treated  in 


82       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

approximately  the  same  way.  Immediately  on  entrance  to  the 
hospital,  the  patient's  blood  pressure  is  taken,  a  catheterized 
specimen  of  urine  obtained  and  she  is  put  into  an  isolation  room 
which  is  darkened  and  as  much  quiet  as  possible  obtained.  She 
is  then  given  by  hypodermatic  injection  Vz  grain  morphin  sul- 
phate, her  stomach  is  washed  out,  2  ounces  of  castor  oil  is  poured 
down  the  tube  at  the  end  of  the  lavage  and  she  is  given  a  colonic 
irrigation  of  5  gallons  of  5  per  cent  glucose  solution.  If  the 
blood  pressure  is  over  175  systolic,  phlebotomy  is  done  and  a 
sufficient  quantity  of  blood  is  extracted  to  bring  the  pressure 
down  to  150.  The  patient  is  now  kept  quiet  and  I/4  grain  morphin 
administered  every  hour  until  the  respirations  drop  to  eight  per 
minute.  At  this  time  convulsions  have  usually  ceased,  the  patient 
will  have  fallen  into  labor,  and,  as  has  happened  in  practically  all 
the  cases,  will  deliver  herself  in  a  short  time.  Of  the  cases  in- 
cluded, twenty-three  were  spontaneous  deliveries,  nine  were 
delivered  by  low  forceps,  two  by  version  and  breech  extraction, 
one  breech  presentation  and  delivery.  All  the  patients  in  whom 
a  fetal  heart  was  heard  on  admission  were  delivered  of  living 
children,  and  in  none  of  these  were  there  any  signs  whatever  of 
the  morphin  which  had  been  administered  to  the  mother. — The 
Journal  of  the  American  Medical  Association. 


PosT-]\IoRTEM   Caesarian   Section. 


Harrar  (Edinburgh  Medical  Journal,  October,  1916)  quotes 
an  interesting  article  with  conclusions  as  follows : 

It  is  quite  obvious  that  the  death  of  a  pregnant  patient  unde- 
livered places  her  medical  attendant  in  a  delicate  position,  and 
this  may  easily  become  one  of  acute  embarrassment  if  her  rela- 
tives refuse  permission  for  the  section,  which  may  be  the  only 
means  of  delivering  the  child  within  the  six  or  seven  minutes 
which  is  all  the  time  that  can  be  safely  allowed  to  elapse  after 
the  maternal  decease,  if  the  infant  is  to  have  a  fair  chance  of 
recovery.  On  the  one  side  he  may  be  faced  with  a  peremptory 
refusal  of  permission,  and  on  the  other  side  he  is  responsible 


EXTRACTS  FROM  JOURNALS  83 

for  the  life  of  the  unborn  child ;  further,  he  has  no  time  for  con- 
sultation and  argument.  Tlie  situation  is  certain  to  be  a  delicate 
one,  but  apparently  he  not  only  may,  but  he  ought  to,  extract  the 
child  on  his  own  and,  it  may  be,  on  his  sole  responsibility,  and, 
so  far  as  statistics  can  give  a  guide,  he  ought  to  employ  the 
Caesarian  section  as  the  method  of  extraction.  A  further  diffi- 
culty is  that  the  death  is  usually  sudden  and  may  be  also  quite 
unexpected,  and  an  added  responsibility  is  now  to  be  discovered 
in  the  possibility  of  an  action  for  culpable  negligence  if  surgical 
measures  to  deliver  the  child  are  not  taken.  Certainly  no  prac- 
titioner of  medicine  cafl  afford  to  leave  his  conduct  in  such  cir- 
cumstances to  be  settled  by  resolutions  formed  for  the  first  time 
in  the  presence  of  the  emergency.  If  it  were  possible,  the  doctor's 
difficulties  are  added  to  when  he  is  dealing  with  not  a  dead  but 
a  moribund  pregnant  woman. — The  Therapeutic  Gazette. 


Disorders  of  the  Female  B/ladder. 


In  the  September,  1916,  issue  of  the  Urologic  and  Cutaneous 
Rez'iezi.',  Robert  B.  Stewart,  of  Topeka,  Kansas,  discusses  "Dis- 
orders of  the  Female  Bladder,"  from  the  viewpoint  of  the  gen- 
eral surgeon.  Dr.  Stewart  points  out  that  the  element  of  pain, 
frequency  of  urination,  and  the  presence  or  absence  of  blood 
and  of  pus  in  the  urine  must  be  considered  in  all  forms  of  bladder 
irritation.  In  determining  a  diagnosis  often  an  examination  of 
the  urine  and  subsequent  cystoscopy  will  reveal  a  cystitis  or  a 
suppurative  lesion  of  the  kidney,  wherein  there  are  no  symptoms 
directing  attention  to  the  bladder. 

Cystitis  is  always  a  secondary  process,  and  it  is  of  the  utmost 
importance  to  determine  the  primary  cause.  Cystitis  which  often 
follows  the  retention  of  urine  in  post-operative  cases  is  not  alto- 
gether due  to  catheter  infection,  but  to  the  irritating  effect  pro- 
duced by  the  residual  urine.  The  administration  of  urotropin  in 
sufficient  doses  to  produce  the  physiological  effect  of  the  drug 
upon  the  bladder,  given  previous  to  operation,  will  do  away  with 
post-operative  retention  of  urine.     This  is  the  first  reference  to 


84       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

the  employment  of  urotropin  for  this  purpose  which  we  are  able 
to  find  in  medical  literature. 

The  various  causes  of  hematuria  and  the  sources  of  pus  appear- 
ing in  urine  are  discussed.  The  cystoscope  is  of  the  most  vital 
importance  in  determining  the  source  of  hemorrhage  and  infec- 
tion, and  should  be  used  in  all  cases  wherein  it  is  not  directly 
contra-indicated. 

Regarding  the  diagnosis  of  calculus,  a  stone  in  the  urinary 
tract  which  is  not  of  sufficient  density  to  cast  a  shadow  heavier 
than  the  surrounding  structures  on  account  of  its  porous  forma- 
tion, will  readily  absorb  sufficient  colorgol  to  render  it  easily 
visible  on  the  radiogram. 

Bladder  tumors  seldom  occasion  symptoms  until  the  advent  of 
infection  which  gives  rise  to  hematuria  and  pyuria.  These 
tumors  are  easily  found  by  the  use  of  the  cystoscope,  and  the 
probability  of  their  benign  or  malignant  nature  determined. 

The  one  point  which  the  author  emphasizes  is  the  vast  im- 
portance of  careful  cystoscopic  study  as  a  routine  procedure  in 
all  cases  of  women  presenting  symptoms  of  bladder  irritation. 
For  upon  accurate  determination  of  the  cause  in  this  class  of 
cases  alone  depends  the  choice  of  suitable  therapeutic  measures 
which  are  to  be  employed. — Medical  Review  of  Reviews. 


EDITORIALS  86 


lElittortal 


Publish br's  Notice— The  Journal  is  published  in  monthly  numbers  of  48  pasrea 
at  $1.00  a  year,  to  be  always  paid  in  advance. 

All  bills  for  advertisements  to  be  paid  quarterly,  after  the  first  insertion  of  the 
auarter. 

Business  communications,  remittances  by  mail,  either  by  money  order,  draft,  or 
r«^9tered  letter,  should  be  addressed  to  the  Business  manager.  C.  S.  Briggs,  M.  D. 
comer  Summer  and  Union  Streets.  Nashville,  Tenn. 

All  communications  for  the  Journal,  books  for  review,  exchanges,  etc.,  should  be 
addressed  to  the  Editor. 


Prohibition. 


Our  excuse  for  writing  again  on  this  subject  is  the  fact  that 
the  United  States  Supreme  Court  has  declared  the  Webb-Kenyon 
law  constitutional.  This  decision  furnishes  food  for  thought, 
both  of  a  retrospective  and  prospective  kind. 

Retrospectively  we  see  how  ineffective  have  been  the  prohi- 
bition laws  passed  by  the  different  states;  real  prohibition  has 
not  been  obtained,  but  instead,  whiskey,  brandy,  gin  and  patent 
medicines  have  been  substituted  for  beer  and  wines,  and  before 
the  Harrison  anti-narcotic  law  went  into  effect,  dangerous  nar- 
cotics were  used  to  obtain  the  sensation  and  sense  of  well-being 
hitherto  secured  by  alcoholic  drinks.  Moreover,  a  general  dis- 
regard for  laws  of  all  kinds  has  crept  in  and  the  liquor  question 
has  become  a  more  serious  disturbing  question  in  state  and 
municipal  elections  than  heretofore. 

So,  retrospectively  we  see  that  both  the  Harrison  and  the 
Webb-Kenyon  laws  should  have  been  effective  before  a  single 
state  voted  dry,  and,  furthermore,  that  the  closed  saloon  and  the 
bar  should  have  been  abolished  before  any  attempt  was  made  to 
abolish  the  products  sold. 

With  these  weaknesses  of  state-wide  prohiibtion  before  us, 
prospectively,  we  see  certain  rational  steps  that  should  be  taken 
before  we  try  national  prohibition.  In  our  humble  opinion  these 
are  as  follows : 

I.  The  Harrison  law  should  be  even  more  effective  than  at 
present;  we  have  only  to  imagine  national  prohibition  to  realize 


86       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

how  difficult  it  will  be  for  the  anti-narcotic  law  to  remain  effec- 
tive. Smuggling  narcotics  will  be  a  highly  lucrative  business, 
and  the  recent  feats  of  submarines,  especially  the  Deutschland, 
should  warn  us  that  our  coast  patrol  system  will  have  to  be 
greatly  strengthened  if  the  Harrison  law  is  to  be  enforced  in  the 
face  of  national  prohibition. 

2.  The  pure  food  and  drugs  law  should  be  made  so  stringent 
that  no  medicine  containing  alcohol  could  be  sold  without  a 
physician's  prescription.  This  would  not  only  prevent  the  use 
of  patent  medicines  instead  of  liquor,  as  in  the  past,  but  would 
help  abolish  that  nefarious  business. 

3.  The  pharmacopeia  should  substitute  aquas  and  fluid  extracts 
for  tinctures  and  fluid  extracts  wherever  the  nature  of  the  drugs 
would  permit.  The  effect  of  the  drugs  would  not  be  lost  and  at 
the  same  time  the  latent  craving  for  alcohol,  which,  unfortunately, 
is  present  in  most  individuals,  would  not  be  stimulated. 

4.  Prohibition  states  which  still  allow  a  certain  amount  of 
whiskey,  beer,  etc.,  per  capita  to  be  shipped  into  the  state  should 
change  the  law  so  that  no  alcoholic  drink  could  be  shipped  into 
the  state,  and  all  states  voting  prohibition  in  the  future  should 
pass  similar  laws.  Only  in  this  manner  can  the  Federal  govern- 
ment know  the  real  sentiment  of  the  mass  of  people  and  so  know 
when  it  would  be  for  the  best  interest  of  all  to  pass  a  national 
prohibition  law. 

5.  Federal  licenses  should  not  be  sold  in  dry  territory. 

6.  With  the  consent  of  the  states — and  it  would  be  easy  to 
obtain — the  closed  saloon  and  the  bar  should  be  absolutely  abol- 
ished from  the  country.  Drinks  should  be  served  only  in  cafes, 
restaurants  and  hotels,  and  only  at  tables. 

7.  Taxes  on  all  intoxicating  drinks  should  be  increased,  the 
increase  to  be  made  in  a  certain  ratio  to  the  percentage  of  al- 
cohol. This  would  not  only  lower  the  general  consumption,  but 
would  effect  especially  boys,  young  men  and  the  poor  working 
man,  the  classes  especially  aimed  at  by  prohibition.  It  would 
also  increase  the  governmental  revenues. 

8.  Government  requirements  should  be  more  exacting  than  at 
present,  so  that  only  good  brandies,  whiskies,  wines,  etc.,  are  sold. 


EDITORIALS  87 

9.  The  Federal  law  against  teaching  the  use  of  preventives  in 
its  effects  indirectly  cause  the  same  evils  that  alcohol  causes, 
and,  moreover,  is  a  potent  cause  of  alcoholism  itself.  Therefore, 
this  law  should  be  repealed  before  we  try  national  prohiibtion 
as  a  means  of  improving  the  nation. 

10.  A  commission  of  disinterested  scientists  should  be  ap- 
pointed to  determine  whether  national  prohibition  at  the  present 
time  would  be  for  the  best  interest  of  the  nation. 

We  must  bear  in  mind  the  failure  of  state  prohibition,  the  sub- 
stitution of  other  stimulants  for  alcohol,  the  inherited  desire  for 
stimulants  of  those  whose  forebears  have  been  drunkards  or 
neurotics,  and  the  real -innate  desire  for  stimulants  found  in  all 
races ;  we  must  not  forget  the  disastrous  effect  of  "firewater" 
on  the  American  Indian,  in  whom  heredity  played  but  a  small 
part,  since  their  own  intoxicating  drinks  were  neither  palatable 
nor  potent;  and  we  must  consider  the  fact  that  with  increasing 
knowledge  and  civilization  temperance  necessarily  increases  pari 
passu  with  increase  in  self-control,  and  that  the  increased  tem- 
perance of  our  citizens  today  compared  with  their  ancestors  is 
not  due  as  much  to  prohibition  laws  as  to  a  natural  evolutionary 
change. 

Finally,  the  question  each  man  must  ask  himself  is  whether  it 
is  better  to  train  this  self-control  and,  after  after  hedging  the 
liquor  monster  around  on  all  sides,  let  her  die  from  starvation, 
as  she  surely  will  at  no  very  distant  time,  or  whether  it  is  better 
to  try  to  kill  her  outright  and  in  her  death  throes  give  birth  to 
other  monsters  a  thousand  times  more  dangerous  and  difficult 
to  kill.  W.  T.  B. 


Do  You  Know  That 


Efficiency  decreases  as  fatigue  increases? 

The  full  pay  envelope  is  the  great  enemy  of  tuberculosis? 

A  reliable  disinfectant  which  may  be  made  for  50  cents  per 
gallon  has  been  devised  by  the  U.  S.  Public  Health  Service? 

The  maintenance  of  health  is  the  first  duty  of  the  patriotic 
American  ? 


88       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Exercise  in  the  open  air  cures  and  prevents  many  ills  ? 
Typhoid  fever  is  contracted  by  swallowing  sewage? 
Unpasteurized  milk  kills  many  babies? 


Opportunity  for  Young  Medical  Men — Government  Filling 
Vacancies  in  Public  Health  Service. 


According  to  a  statement  just  issued  by  Surgeon  General 
Rupert  Blue,  young  medical  men  between  the  ages  of  23  and  32 
will  be  given  an  opportunity  each  month  to  demonstrate  their 
fitness  for  admission  to  the  grade  of  assistant  surgeon  in  the 
U.  S.  Public  Health  Service.  There  are  several  vacancies  in  the 
government's  mobile  sanitary  corps,  which  is  now  in  the  one 
hundred  and  nineteenth  year  of  its  existence,  but  in  order  to  be 
recommended  to  the  President  for  commission,  a  physical  and 
professional  examination  must  first  be  passed.  As  the  tenure  of 
office  is  permanent  and  the  public  health  officers  are  ordered  to 
duty  in  all  parts  of  the  world,  they  are  required  to  certify  that 
they  believe  themselves  free  from  any  ailment  which  would  dis- 
qualify them  for  service  in  any  climate.  Boards  will  be  convened 
at  Washington,  Boston,  New  York,  Chicago,  St.  Louis,  Louis- 
ville, New  Orleans  and  San  Francisco,  but  permission  to  take 
the  examination  must  first  be  obtained  from  the  Surgeon  General. 
The  examination  is  searching  and  includes,  in  addition  to  the 
various  branches  of  medicine,  surgery  and  hygiene,  the  subjects 
of  the  preliminary  education,  history,  literature  and  the  natural 
sciences.  The  commissions  will  be  issued  as  assistant  surgeon, 
and  after  four  years  of  service  the  young  officers  are  entitled  to 
examination  for  promotion  to  the  grade  of  passed  assistant 
surgeon,  and  after  twelve  years  of  service  to  another  examina- 
tion for  promotion  to  the  grade  of  surgeon.  The  annual  salaries 
are :  Assistant  surgeon,  $2,000 ;  passed  assistant  surgeon,  $2,400 ; 
surgeon,  $3,000;  senior  surgeon,  $3,500;  assistant  surgeon  gen- 
eral, $4,000.  When  the  government  does  not  provide  quarters, 
commutation  at  the  rate  of  $30,  $40  and  $50  a  month,  according 
to  grade,  is  allowed.     All  grades  receive  longevity  pay,  that  is, 


EDITORIALS  89 

io%  in  addition  to  the  regular  salary  for  every  five  years  until 
the  maximum  of  40%  is  reached.  When  officers  travel  on  offi- 
cial duties  thev  are  reimbursed  their  actual  traveling  expenses. 


Editor  The  Journal  of  Medicine  and  Surgery,  Nashville,  Tenn.: 

Dear  Sir — The  second  examination  to  be  given  by  the  Na- 
tional Board  of  Medical  Examiners  will  be  held  in  Washington, 
D.  C,  June  13,  191 7.    The  examination  will  last  about  one  week. 

The  following  states  will  recognize  the  certificate  of  the  Na- 
tional Bjoard:  Colorado.  Delaware,  Idaho,  Iowa,  Kentucky, 
Maryland,  North  Carolina,  New  Hampshire,  North  Dakota  and 
Pennsylvania.  Favorable  legislation  is  now  pending  in  twelve 
of  the  remaining  states. 

A  successful  applicant  may  enter  the  reserve  corps  of  either 
the  army  or  navy  without  further  professional  examination,  if 
their  examination  papers  are  satisfactory  to  a  board  of  exam- 
iners of  these  services. 

The  certificate  of  the  National  Board  will  be  accepted  as  quali- 
fication for  admittance  into  the  Graduate  School  of  the  Univer- 
sity of  Minnesota,  including  the  Mayo  Foundation. 

Application  blanks  and  further  information  may  be  obtained 
from  the  secretary,  Dr.  J.  S.  Rodman,  2106  Walnut  Street, 
Philadelphia. 

We  will  appreciate  a  notice  of  this  coming  examination  in 
your  journal.  Very  truly  yours, 

J.  S.  Rodman, 
—  Secretary. 

BOERHAAVE. 


A  clergyman  living  near  Leyden  was  the  father  of  thirteen 
children.  The  eldest,  born  December  31,  r668,  was  Herman 
Boerhaave,  accounted  by  many  the  most  famous  physician  not 
only  of  the  eighteenth,  but  probably  of  any,  century.  He  died  of 
gout  in  1738. 

He  was  an  indefatigable  teacher,  sometimes  lecturing  five 
hours  a  dav  to  his  students  at  Levden.    He  was  the  first  to  give 


90       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

separate  lectures  on  ophthalmology  (the  science  of  diseases  of  the 
eye)  and  to  use  a  magnifying  glass  in  the  examination  of  the 
eye.  He  combined  with  a  desire  to  study  disease  at  the  bedside, 
a  freedom  from  theoretical  and  philosophical  influence  which 
led  him  to  use  the  most  modern  diagnostic  apparatus  which  he 
could  secure.  He  was  so  famous  that  a  Chinese  official  once 
sent  him  a  letter  addressed  simply,  "To  the  most  famous  physician 
in  Europe."    His  maxim  was  "simplicity  is  the  seal  of  truth." 

The  modern  diagnosis  of  disease  aims  to  employ  every  method 
which  will  reveal  the  exact  mental  and  physical  condition  of  the 
patient.  Psycho-analysis  will  reveal  the  depths  of  the  patient's 
mind  almost  as  clearly  as  the  X-ray  shows  the  broken  bone  hid- 
den beneath  the  body  tissues.  The  pressure  of  the  blood  against 
the  vessel  walls  may  be  accurately  measured  and  appropriate 
means  taken  to  ward  off  an  apoplectic  attack.  The  bodily  ex- 
cretions may  be  analyzed  and  the  efficiency  of  the  excretory 
organs  determined.  Special  apparatus  permits  the  examination 
of  the  eye,  the  ear,  the  nose,  throat,  bronchi,  and  the  interior  of 
various  other  parts  of  the  body.  Nothing  is  taken  for  granted; 
the  blood  is  examined;  the  activity  of  the  stomach  is  estimated; 
the  validity  of  the  nervous  system  is  looked  into.  The  modern 
physician  finds  the  disease  before  he  treats  it. 

Accurate  diagnosis  is  of  importance  to  the  public  health  be- 
cause an  early  and  correct  knowledge  of  the  presence  of  a  dis- 
ease affords  opportunity  to  prevent  its  spread.  The  case  of 
tuberculosis  which  is  found  early  has  an  infinitely  greater  chance 
of  recovery  than  the  one  which  is  found  late.  Boerhaave  recog- 
nized these  facts  in  a  general  way  and  applied  them;  in  fact, 
according  to  Rohlfs,  he  was  the  first  who  made  a  chemical  ex- 
amination of  some  of  the  bodily  excretions. 


REVIEWS  AND  BOOK  NOTICES  91 


fi^htrhts  nv^  Hank  NntirtB 


The  Newer  Methods  of  Blood  and  Urine  Chemistry,  by  R.  B.  H.  Grad- 
wohl,  M.D..  Director  of  the  Pasteur  Institute  of  St.  Louis  and  the 
Gradwohl  Laboratories.  St.  Louis,  and  A.  J.  Blaivas,  Assistant  in  the 
same ;  sometime  Technician  in  Pathological  Chemical  Laboratories,  New 
York  Post-Graduate  Medical  School  and  Hospital;  and  Former  As- 
sistant, Chemical  Laboratory  St.  Luke's  Hospital,  New  York  City.  With 
Sixty-five  Illustrations  and  Four  Color  Plates.  St.  Louis,  C.  V.  Mosby 
Company,  191 7. 

We  feel  sure  that  the  profession  will  be  pleased  with  this  new 
claimant  for  favor,  inasmuch  as  it  supplies  a  reliable  guide  for 
the  character  of  investigation  becoming  very  day  more  em- 
ployed by  physicians  in  their  daily  practice.  It  is  simply  a  con- 
densation in  book  form  of  information  scattered  through  current 
medical  literature  and  in  this  form  made  available  for  the  every- 
day work  of  the  practical  physician.  Only  one  method  is  given 
for  each  test,  as  the  authors  know  what  the  majority  of  workers 
along  this  line  judge  the  best  test  to  be.  We  feel  sure  the  book 
will  prove  a  handy  vade  mecum  for  physicians,  and  that  it  will 
.  be  generally  adopted  as  a  guide  to  every-day  laboratory  work. 


Department  of  Commerce,  Bureau  of  the  Census.  Sam  L.  Rogers.  Di- 
rector. Mortality  from  Cancer  and  Other  Malignant  Tumors  in  the 
Registration  Area  of  the  United  States.  1914-  Washington  Government 
Printing  Office,  1915- 

We  are  in  receipt  of  this  valuable  compilation  and  would  call 
the  attention  of  the  profession  to  its  importance  as  an  index  to 
the  terrible  ravages  in  this  country  of  this  scourge  of  humanity. 
The  accuracy  and  thoroughness  with  which  the  work  has  been 
done  is  unquestionable  and  the  statistics  are  so  terrifying  as  show- 
ing the  menace  of  the  disease  that  we  have  no  doubt  the  search 
into  the  causes,  the  prevention  and  the  treatment  of  cancer  will 
be  wonderfully  stimulated  to  increased  efforts  in  the  study  of  this 
disease. 


92       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Handbook  of  Suggestive  Therapeutics,  Applied  Hypnotism,  Psychic 
Science.  A  Manual  of  Practical  Psychotherapy,  Designed  Especially 
for  the  Practitioner  of  Medicine  and  Dentistry,  by  Henry  S.  Munro, 
M.D.,  Omaha,  Nebraska.  Fourth  Edition,  Revised  and  Enlarged.  St. 
Louis,  C.  V.  Mosby  Company,  1917. 

Our  thanks  are  due  the  enterprising  publishers  for  a  copy  of 
this  interesting  and  practically  useful  book,  which  is  presented 
in  its  fourth  edition,  with  careful  revision  and  considerable  addi- 
tions. The  author  deals  with  a  subject  that  is  claiming  more  and 
more  of  the  practitioner's  attention.  Psychotherapy  enters 
largely  into  the  every-day  treatment  of  disease  and  is  used  con- 
sciously or  unconsciously  by  the  practitioner  in  the  management 
of  every  patient  he  has  in  charge.  Many  useful,  practical  hints 
are  given  and  the  technique  of  the  method  is  fully  demonstrated. 
We  unhesitatingly  recommend  the  book  to  physicians,  as  it  con- 
tains much  that  will  interest  and  instruct  them  in  the  art. 


Progressive  Medicine — A  Quarterly  Digest  of  Advances,  Discoveries  and 
Improvements  in  the  Medical  and  Surgical  Sciences.  Edited  by  Hobart 
Amory  Hare,  M.D.,  Professor  of  Therapeutics,  Materia  Medica  and 
Diagnosis  in  the  Jefferson  Medical  College,  Philadelphia,  Assisted  by 
Leighton  F.  Appleman,  M.D.,  Instructor  in  Therapeutics,  Jefferson 
Medical  College,  Philadelphia.  Vol  XX,  No.  i.  Whole  Number  73. 
March  i,  1917.  Owners  and  Publishers,  Lea  and  Febiger.  Philadelphia, 
New  York.     Six  Dollars  per  Annum. 

Our  thanks  are  due  the  obliging  publishers  for  this  very  inter- 
esting number  of  a  valuable  serial.  This  quarterly  publication 
occupies  a  place  peculiarly  its  own  and  appeals  to  the  busy 
practitioner  as  a  storehouse  of  useful  information,  the  pickings 
of  up-to-date  literature  in  condensed  form  selected  by  a  corps 
of  contributors  who  know  how  to  separate  the  grain  from  the 
chaff.    The  contents  of  this  number  are  as  follows : 

Surgery  of  the  Head  and  Neck,  by  Charles  H.  Frazier,  M.D. ; 
Surgery  of  the  Thorax,  Excluding  Diseases  of  the  Breast,  by 
George  P.  Muller,  M.D. ;  Infectious  Diseases,  Including  Acute 
Rheumatism,  Croupous  Pneumonia  and  Influenza,  by  John 
Ruhrah,    M.D.;   Diseases   of   Qiildren,   by   Floyd  M.   Crandall, 


REVIEWS  AND  BOOK  NOTICES.  98 

M.D. ;   Rhinology,   Larygology    and    Otolog>%   by    George    M. 
Coates,  A.B.,  I\I.D. ;  Index. 

Each  section  represents  in  its  text  the  last  word  upon  the  sub- 
ject of  which  it  treats,  and  is  a  mine  of  useful  knowledge  ready 
for  use.  The  progressive  practitioner  can  not  do  better  than  by 
becoming  a  regular  subscriber  to  this  excellent  periodical. 


94       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


"Solution  of  Albuminate  of  Iron"  (Liquor  Ferri  Albuminatis, 
Flexner).  Contains  13%  Alcohol.  Each  teaspoonful  of  this 
preparation  represents  one  grain  of  Dry  Albuminate  of  Iron  in 
permanent  solution.  A  most  valuable  form  of  Iron  Tonic.  Pre- 
pared by  Robinson-Pettet  Co.,  Incorporated,  Louisville,  Ky.  (See 
page  —  this  issue.) 


Sanmetto  is  a  mild,  non-irritating  diuretic,  which  allays  urinary 
irritation  and  increases  urinary  secretion.  It  is  thought  of  in 
prostatitis,  pyelitis,  purulent  or  catarrhal  crystitis,  irritable  con- 
dition of  the  bladder,  gonorrhea,  enuresis  in  children,  and  in 
fevers  where  a  mild  diuretic  is  desirable  to  increase  the  secretion 
of  urine.  Sanmetto  has  been  used  by  thousands  of  physicians 
in  old  men  with  irritable  bladder  and  difficult  urination,  and  they 
have  found  in  a  very  satisfactory  medicine.  It  is  safe  and  harm- 
less, and  by  its  soothing  action  on  the  mucous  membrane  of  the 
bladder,  it  relieves  the  irritation  and  adds  greatly  to  the  comfort 
of  the  patient.  It  increases  the  flow  of  urine,  lessens  the  specific 
gravity,  clears  up  cloudy  urine,  and  relieves  undue  acidity.  In 
all  these  ways  it  is  of  great  benefit  to  the  patient.  In  enlarged 
prostate  it  has  done  good  service  by  its  soothing  qualities  while 
reducing  the  enlargement. 


Chronic  Cardiac  Disease. 


The  patient  with  organic  heart  disease  needs  constant  atten- 
tion to  his  digestion  and  nutrition.  A  little  falling  off  in  the 
general  vitality  and  the  compensatory  status  of  the  heart  may 
be  lost  forever.  At  the  first  sign  of  nutritional  decline,  therefore, 
Gray's  Glycerine  Tonic  Comp.  should  be  given.  This  dependable 
tonic  braces  a  vVavering  organism  by  reinforcing  weakened  func- 


PUBLISHERS'  DEPARTMENT  95 

tions.  Thus  it  not  only  directly  contributes  to  cardiac  power, 
but  what  is  vastly  more  important,  materially,  reduces  the  stress 
under  which  a  feeble  heart  constantly  has  to  labor.  In  other 
words,  while  increasing  the  carrying  power  of  the  heart,  it  also 
decreases  the  burden. 


The  Interol  Treatment  of  Chronic  Constipation 
IN  the  Elderly 


is  rational.  It  fills  one  want,  in  a  harmless  and  effective  way, 
namely,  the  want  of  coFonic  lubrication. 

While  lubricating,  it  also  acts  beneficially  by  softening — or, 
rather,  by  keeping  soft — the  intestinal  contents,  and  by  pro- 
tecting any  bare  spots  in  the  tract.  Finally,  it  combats  the  ac- 
companying auto-toxemia  by  sluicing  out  the  feces  with  their 
toxins,  as  is  evidenced  by  the  improvement  in  complexion  and 
in  general  well-being  shown  by  many  of  these  patients  after 
steadily  using  INTEROL. 

All  this  is  done  without  enervation  to  an  already  weakened 
organism. 

Is  there  any  one  thing  at  the  physician's  command  that  will  do 
as  much  for  these  patients?* 


In  Scarlet  Fever  and  Measles 


there  is  no  procedure  that  will  contribute  so  markedly  to  a 
patient's  comfort  and  well-being  and  at  the  same  time  prove  so 
serviceable  from  prophylactic  standpoints,  as  anointing  the  whole 
body  at  frequent  intervals  with  K-Y  Lubricating  Jelly  (Reg.  U. 
S.  Pat.  Oiif.).  Itching  and  irritation  are  relieved  at  once,  and 
while  the  activity  of  the  skin  is  maintained,  the  dissemination 
of   infectious   material   is   also  prevented.     So  notable  are  the 


^Further  literature  on  this  subject  on  request.     Van  Horn  &  Sawtell, 
15-17  E.  40th  St.,  New  York  City. 


96       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

benefits  that  result  from  the  use  of  this  non-greasy,  water-soluble 
and  delightfully  clean  product  that  its  use  has  become  a  matter 
of  routine  in  the  practice  of  many  physicians.  In  addition  to 
being  ''the  perfect  lubricant,"  K-Y  has  also  been  found  an  ideal 
emollient,  and  in  no  way  does  it  demonstrate  its  great  utility 
more  convincingly  than  in  the  care  of  the  skin  during  the  ex- 
anthematous  affections.  Van  Horn  &  Sawtell,  15-17  East  40th 
Street,  New  Rork  City,  and  31-33  High  Holborn,  London, 
England. 


TONGALINE 


"Having  devoted  especial  attention  to  the  treatment  of  chronic 
diseases,  I  think  I  can  attribute  a  large  part  of  what  success  I 
have  had  to  the  strict  attention  I  have  always  given  to  the  matter 
of  elimination.  A  large  percentage  of  such  diseases  have  as  a 
main  factor  autointoxication  and  the  retention  of  morbid  waste 
matters  nature  fails  to  expel." 

Tongaline,  by  its  stimulating  action  upon  the  liver,  the  bowels, 
the  kidneys  and  the  pores  is  the  ideal  eliminative  and  its  use  will 
invariably  be  attended  with  satisfaction  to  the  physician  and  the 
patient. 


NASHVILLE  JOURNAL 

OF 

MEDICINE  AND    SURGERY 


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


Vol..  CXI.  APRIL,  1917.  No.  4 


©ngtttal  QlnmmumrationB 


APPENDICITIS  COMPLICATING  PREGNANCY. 


BY  AIME'  PAUL  HEINECH,  M.D., 

Professor  of  Surgery,  Chicago  College  of  Medicine  and 
Surgery,  Chicago. 


Appendicitis  attacks  all  ages  and  both  sexes.  Though  distinctly 
a  surgical  disease,  it  is  also  of  great  practical  interest  to  gynecolo- 
gists, obstetricians  and  general  practitioners. 

The  frequency  of  appendicitis  in  the  fernale  pregnant  or  non- 
pregnant is  underestimated  and  its  significance  not  fully  appre- 
ciated. It  is  often  overlooked,  misdiagnosed  and  therefore  im- 
properly treated.  The  autopsy  findings  often  bring  the  first  inti- 
mation of  the  true  cause  of  the  clinical  picture. 

To  serve  our  fellow  practitioners,  we  collected,  analyzed  and 
studied  the  original  reports  of  all  the  operated  cases  of  appendi- 
citis occuring  during  pregnancy,  that  are  to  be  found  in  the 
French,  English  and  German  medical  literature  from  1900  to  1915, 
inclusive,  and  also  some  unpublished  personal  cases.  Cases  re- 
ported with  insufficient  data  were  not  considered. 


98       NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

The  subject  will  be  discussed  under  the  following  sub-heads : 

1.  Incidence. 

2.  Etiology. 

3.  Combined  appendicitis  and  extra-uterine  pregnancy, 

4.  Pathology. 

f  5.  Co-existing  conditions. 

Influence  of  pregnancy  upon  appendicitis. 
Influence  of  appendicitis  upon  pregnancy. 

6.  Diagnosis. 

7.  Differential  diagnosis. 

(a)  Maternal. 

(b)  Fetal. 

8.  Prognosis. 

9.  Treatment. 

(a)  Prophylaxis. 

(b)  Indication  for  operation. 

(c)  Operative. 

10.  Post-operative  sequelae. 

11.  Summary. 

INCIDENCE. 

During  the  child-bearing  age,  woman  is  at  no  time  exempt  from 
attacks  of  appendicitis.  In  forty-six  of  our  selected  cases,  the  age 
is  not  stated.    The  remaining  patients  were  at  time  of  operation : 

Under  18  years — 3  cases. 

18 — 20  years,  inclusive 13  cases. 

21 — 25  years,  inclusive 33  cases. 

26 — 30  years,  inclusive 42  cases. 

31 — 35  years,  inclusive 23  cases. 

36 — 40  years,  inclusive 12  cases. 

One  patient  forty-two  years. 

The  condition  occurs  in  primiparae  and  multiparae ;  in  first  early 
and  late  pregnancies ;  in  single  and  twin  pregnancies.  Appendici- 
tis can  coexist  with  other  disease  processes  to  which  it  may  be 
primary,  secondary  or  coincidental. 


ORIGINAL  COMMUNICATIONS  99 

In  the  cases  forming  the  basis  of  this  article,  there  are  noted 
thirty  primiparge,  twenty  deutiparae,  thirty-seven  miiltiparae. 

The  number  of  previous  pregnancies,  if  there  were  any,  is  not 
stated  in  eighty-three  cases.  Appendicitis  occurs  at  all  periods 
of  gestation.  In  some  cases  the  disease  antedated  pregnancy; 
some  cases  were  operated  early  with  reference  to  onset  of  symp- 
toms ;  some  late.  It  is  recorded  that  operation  was  indicated  and 
performed : 

During  the  first  3  months  of  gestation 40  times 

From  4 — 6  months,  inclusive 28  times 

From  7 — 9  months,  inclusive 28  times 

Period  of  gestation  not  stated 45  times 

ETIOLOGY. 

The  etiology  of  appendicitis  in  a  pregnant  woman  is  the  etiol- 
ogy of  appendicitis  in  the  non-pregnant  woman.  It  is  the  belief 
of  many  clinicians  that  gestation  does  not  exert  any  influence, 
good  or  bad,  upon  the  normal  appendix. 

Appendicitis  is  primary  or  secondary;  it  may  be  secondary  to 
disease  of  the  uterine  adnexa  just  as  inflammatory  diseases  of  the 
tube  and  ovary  may  be  secondary  to  an  appendicitis.  Recurrent 
attacks  of  appendicitis  may  be  precipitated  by  pregnancy,  labor 
or  puerperium.  Pregnancy  can  provoke  acute  inflammatory  dis- 
turbances in  an  appendix  bound  down  by  dense  adhesions  or  con- 
taining a  foreign  body,  one  or  more  feces  concretions,  or  worms. 
The  appendicitis  complicating  pregnancy  may  be  the  patient's 
first  attack.  It  may  have  been  preceded  by  one,  two,  three  or 
more  attacks  of  greater  or  less  severity. 

COMBINED   APPENDICITIS    AND    EXTRA-UTERINE   PREGNANCY. 

In  some  of  the  reported  cases  in  which  appendicitis  and  ectopic 
pregnancy  were  associated,  it  was  not  determined  which  of  the 
two  conditions  antedated  the  other ;  which  was  primary  and  which 
was  secondary. 

When  an  appendicitis  precedes  a  tubal  pregnancy  in  which  it 
apparently  plays  an  etiological  role,  the  anatomical  changes  fre- 
quently evolute  as  follows : 


100     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

1.  Appendicitis. 

2.  Peri-appendicitis. 

3.  Peri-adnexitis. 

4.  Formation  of  inflammatory  adhesions  interfering  with 
tube  mobility  and  tube  function  and  producing  tubal 
malformation. 

5.  Tubal  pregnancy. 

All  these  conditions  fayor  the  ectopic  implantation  of  fertilized 
ova.  Appendicitis  may  hasten  tubal  abortion  through  local  infec- 
tion, through  general  intoxication,  may  lead  to  suppuration  of 
hematoceles  of  fetal  cysts. 

To  differentiate  appendicitis  from  extra-uterine  pregnancy  is 
at  times  difficult.  In  the  unruptured  state,  the  pregnant  tube 
gives  symptoms  analogous  to  those  of  chronic  appendicitis.  An 
infected  hematocele  presents  the  signs  of  suppurative  pelvic  peri- 
tonitis. Peritoneal  hemorrhage  due  to  a  ruptured  tubal  gestation 
sac  has  symptoms  closely  resembling  a  diffuse  septic  peritonitis. 
Positive  Abderhalden  test,  absence  of  fever,  vaginal  hemorrhage, 
symptoms  of  internal  hemorrhage  will  point  to  tubal  pregnancy. 
It  is  interesting  to  make  an  exact  diagnosis,  but  as  both  diseases 
are  surgical  affections  exposing  mother  and  fetus  to  serious  dan- 
gers, the  watchword  in  both  conditions  should  be  early  operation. 
Appendicitis  calls  for  prompt  operative  treatment;  extra-uterine 
pregnancy  is  an  emergency  condition  calling  for  immediate  abla- 
tion of  the  ectopic  fetal  sac. 

In  all  the  cases  of  appendicitis  and  extra-uterine  pregnancy 
herein  considered,  twelve  in  number,  operation  gave  excellent 
results.  The  findings  differed  in  nature  and  consequently  the  op- 
erative procedures  varied  in  extent  in  the  different  cases. 

PATHOLOGY. 

Acute  and  chronic  inflammations  of  the  appendix  involve  the 
organ,  in  part  or  in  its  entirety,  and  are  associated  with  catarrhal, 
fibrinous,  sero-fibrinous,  sero-purulent,  or  purulent  exudates 
present  in  the  cavity  of  the  appendix,  in  its  walls,  or  around  it. 
The  inflammatory  process  may  be  limited  to  the  mucous  mem- 


ORIGINAL  COMMUNICATIONS  101 

brane,  may  involve  part  of,  or  the  entire  thickness  of  the  appen- 
dical  wall. 

The  appendix  vermiformis  may  be  partly  or  wholly  intra-  or 
extra-peritoneal.  A  retro-peritoneal  or  extra-peritoneal  appendix 
the  seat  of  suppurative  inflammation  gives  rise  to  retro-peritoneal 
or  extra-peritoneal  pus  collections.  Adhesive  inflammation  may 
lead  to  permanent  fixation  of  the  appendix,  to  one  or  more  ab- 
dominal viscera  normal  or  pathologic,  to  the  abdominal  parietes, 
or  to  both.  Inflammatory  adhesions  involving  the  tube,  may  an- 
gulate  it,  constrict  it ;  may  interfere  with  tubal  mobility  and  tubal 
function ;  may  changs  its  course  and  play  a  fairly  important  role 
in  the  etiology  of  sterility.  The  appendix,  during  a  280-day  preg- 
nancy, may  touch  every  organ  of  the  abdomen.  Pus  in  quanti- 
ties, large  or  small,  may  be  present  within  the  cavity  of  the  ap- 
pendix, in  its  wall  or  around  it.  Acute  suppurative  inflammation 
of  the  uterus  and  tubes  may  be  set  up  by  direct  extension  from  an 
acutely  inflamed  appendix.  The  walls  of  appendiceal  or  peri- 
appendiceal abscesses  are  formed  in  part  by  one  or  more  of  the 
following  organs :  uterus,  adnexa,  omentum,  intestine,  small  or 
large,  etc.  An  appendicular  abscess  may  bulge  into  the  posterior 
cul-de-sac,  may  open  spontaneously  into  the  uterus,  vagina,  rec- 
tum. 

The  inflammation  proceeded  to  the  state  of  gangrene  in  twenty- 
four  cases;  in  eleven  of  these  cases  one  or  more  perforations 
were  present.  The  gangrene  may  be  limited  to  the  mucous  mem- 
brane, may  afifect  the  entire  appendiceal  wall  or  the  entire  organ. 
Any  part  of  the  organ,  tip,  middle,  base,  may  be  gangrenous. 
Fecal  congretions,  one  or  more,  were  present  in  thirteen  appen- 
dices. It  is  easy  to  understand  how  inflammation  migrates  from 
the  appendix  to  the  Fallopian  tube,  to  the  pregnant  uterus,  etc. 
Pelvic  inflammatory  processes  extending  by  continunity  or  con- 
tiguity of  tissue,  occur  in  the  pregnant  as  well  as  the  non-preg- 
nant. Distal  pus  collections  are  due  to  metastases  by  way  of  the 
lymph  or  blood  channels.  In  the  ulcerative  type  of  inflammation 
the  ulcer  extends  in  depth  and  in  surface  area ;  when  all  the  coats 
of  the  appendix  have  been  burrowed  through,  a  perforation  re- 


102     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

suits.    The  apex,  the  base,  or  any  other  part  of  the  appendix  may 
be  the  seat  of  perforation. 

CO-EXISTING    PATHOLOGICAL    CONDITIONS, 

Co-existing  pathological  conditions  are  primary  or  secondary 
to  the  appendiceal  inflammation  or  merely  coincidental,  bearing 
no  relation  of  cause  or  effect  to  it.  It  is  not  uncommon  for  ap- 
pendicitis in  the  female  to  be  complicated  by  or  associated  with 
tubal  and  ovarian  diseases ;  salpingitis,  pyosalpinx,  hydrosalpinx, 
ovarian  abscess,  tubo-ovarian  abscess,  parametritis,  etc.  Close 
anatomical  association  of  the  appendix  with  the  uterus  and  the 
adnexa  explains  the  frequent  simultaneous  involvement  of  these 
organs  in  disease  processes. 

INFLUENCE  OF  PREGNANCY   UPON    APPENDICITIS. 

Upon  a  normal  appendix,  gestation  has  little  or  no  influence. 
Upon  an  appendix,  the  seat  of  previous  or  latent  disease,  preg- 
nancy exerts  an  unfavorable  influence.  It  can  intensify  an  exist- 
ing inflammation.  It  may  cause  a  previous  inflammation  to  recur. 
In  view  of  this  possibility,  many  of  our  best  clinicians  recommend 
and  practice  the  removal  of  the  appendix  in  women  married  or 
about  to  be  married  who  have  had  one  or  more  attacks  of  appen- 
dicitis non-operatively  treated. 

The  pregnant  uterus  as  it  ascends  in  the  abdomen  commonly 
displaces  the  cecum  and  the  appendix  from  below  up,  from  right 
to  left  and  from  behind  forward.  In  enlarging,  the  uterus  may 
stretch  existing  inflammatory  adhesions ;  it  may  displace,  twist, 
and  kink  the  appendix  and  thereby  whip  into  activity  latent  ap- 
pendicular infections.  Pregnancy  is  a  serious  complication  of 
appendicitis.  1.  When  the  appendix  is  adherent  to  the  uterus. 
2.  When  it  is  the  seat  of  an  inflammation,  perforative,  gangren- 
ous or  suppurative  in  type.  3.  When  its  inflammation  leads  to 
abscess  formation,  near  or  distal.  4.  When  the  uterus  forms 
part  of  the  wall  of  an  appendicular,  peri-  or  para-appendicular 
abscess.  In  the  afore  mentioned  conditions,  adhesions  may  be 
torn,  abscesses  may  be  ruptured  by  the  enlarging  uterus. 


ORIGINAL  COMMUNICATIONS  103 

INFLUENCE  OF  APPENDICITIS  ON  PREGNANCY. 

Appendicitis  is  a  menace  to  the  mother's  Hfe,  it  is  a  menace  to 
the  gestation.  The  danger  increases  with  the  advance  of  gesta- 
tion and  is  most  marked  after  the  fourth  month.  Infection  can 
and  does  spread  from  the  appendix  to  the  genital  organs  by  way, 

1.  Of  the  peritoneum  (localized  or  dififuse  peritonitis).  2.  Of  the 
appendiculo-ovarian  ligament.  3.  Of  adhesions  existing  between 
the  uterus  and  a  perityphlitic  pus  focus.    4.  Of  the  Fallopian  tube. 

Even  a  mild  case  of  appendicitis  may  lead  to  a  plastic  periton- 
itis closing  permanently  the  lumina  of  both  tubes.  From  inflam- 
matory adhesions  may  result  dysmenorrhea,  subinvolution,  ster- 
ility through  inflammatory  closure  of  tubal  ostia,  habitual  abor- 
tion, extra-uterine  pregnancy,  a  tendency  to  uncontrollable  vom- 
iting, etc. 

Appendicitis  in  the  pregnant  state  may  or  may  not  terminate 
pregnancy.  The  prognosis  is  good  as  to  non-interruption  of  preg- 
nancy.    1.  When  the  appendix  does  not  hang  in  the  small  pelvis. 

2.  When  the  inflammation  is  limited  to  the  appendiceal  mucosa. 

3.  When  it  does  not  extend  beyond  the  appendiceal  wall.  4. 
When  the  appendiceal  abscess  or  peri-appendiceal  abscess  is  small. 

Premature  termination  of  gestation  either  by  fetal  death,  fetal 
expulsion  or  both  may  be  caused  by,  1.  Sequels  of  previous  ap- 
pendicitis, acute  or  chronic ;  inflammatory  adhesions,  old  or  recent, 
preventing  uterine  expansion.  2.  Infection  from  the  appendix 
extending  through  the  tubes  to  the  uterus  and  its  contents.  3. 
Infection  reaching  the  placenta  through  lymphatic  and  vascular 
channels.  4.  Metastatic  inflammation  of  the  placenta,  disturbing 
its  circulation.  5.  Local  irritation.  6.  Fatal  effect  of  hyperpy- 
rexia upon  ovum. 

The  further  pregnancy  is  advanced  the  greater  the  danger  of 
abortion  after  operation.  The  chance  of  abortion  after  early  op- 
eration is  very  small  indeed,  for  the  operation  is  then  done  before 
-an  extensive  inflammation  has  involved  the  uterus  or  an  abscess 
rendered  the  patient  septic.  Tendency  to  abortion  is  small  in  clean 
cases  as  in  this  type  the  operative  manipulation  is  reduced  to  a 
minimum. 


104     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

In  173  cases  of  appendicitis  herein  studied  it  is  stated  that  abor- 
tion was  artificially  induced  nine  times  and  occurred  spontaneously 
forty-nine  times.  Caesarian  section  was  performed  four  times, 
abdominal  one,  vaginal  three. 

In  eighty-three  cases,  pregnancy  was  not  interrupted  by  the 
operation.    In  seventeen  cases  no  definite  statement  is  made. 

DIAGNOSIS. 

Appendicitis  is  not  a§  frequently  misdiagnosed  as  formerly. 
Increased  familiarity  with  the  condition  enables  us  to  make  an 
eadier  and  a  more  timely  diagnosis.  It  is  an  established  fact  that 
the  morbidity  and  mortality  of  this  disease  can  be  lessened  if  it 
be  diagnosed  and  operated  before  the  advent  of  complications, 
perforations,  gangrene,  abscess  formation,  peritoneal  involvement, 
etc.  The  diagnostic  difficulties  increase  with  the  advance  of  ges- 
tation and  persist  during  the  puerperium. 

The  symptomatology  of  appendicitis  in  the  pregnant  is  the 
symptomatology  of  the  disease  in  the  non-pregnant.  Neverthe- 
less, the  recognition  of  the  condition  is  made  more  difficult  by 
various  factors.  One  or  more  of  the  cardinal  symptoms  may  be 
lacking.  The  symptoms  and  signs  may  not  be  sufficiently  pro- 
nounced to  lead  to  careful  investigation  or  may  be  classed  among 
the  various  disturbances  incident  to  pregnancy. 

During  pregnancy  the  abdominal  walls  are  on  the  stretch ;  they 
lack  the  softness  and  pliability  so  essential  to  careful  and  satis- 
factory abdominal  palpation.  In  very  fleshy  patients,  palpation 
does  not  give  definite  findings. 

The  seat  of  pain  though  always  corresponding  to  the  site  of 
the  inflammed  appendix,  may  be  abnormally  high.  The  leukocyte 
count  gives  uncertain  findings ;  at  best,  it  has  only  relative  or  cor- 
roborative value. 

Mistakes  are  less  likely  to  occur  by  keeping  in  mind  (a)  that 
every  pregnant  woman  is  to  be  examined   for  physical  defects. 

(b)  That  the  history  is  all  important;  ask  about  previous  attacks. 

(c)  In  gravid  women,  all  attacks  of  indigestion  associated  with 
vomiting  and  fever  should  arouse  suspicion  and  command  a  care- 
ful examination  of  the  abdomen,  (d)  Right  iliac  pain  unassociated 


ORIGINAL  COMMUNICATIONS  105 

with  uterine  contractions  should  lead  one  to  think  of  appendicitis, 
(e)  Deep  seated  retro-cecal  and  other  abscesses  may  be  detected 
by  rectal  examination,  (f)  Peri-  or  para-typhlitic  abscesses  may 
be  detected  by  vaginal  examination. 

In  a  pregnant  woman,  acute  abdominal  pain  of  a  sudden  onset, 
at  first  diffuse  and  then  remaining  localized  to  the  right  iliac  fossa, 
suggests  appendicitis;  more  so  if  the  patient  gives  the  history  of 
previous  attacks. 

DIFFERENTIAL  DIAGNOSIS. 

During  gestation  many  conditions  simulate  appendicitis.  As 
most  of  these  conditions  demand  operative  relief,  the  resulting 
diagnostic  mistakes  are 'embarrassing  and  humiliating  to  the  sur- 
geon, but  not  commonly  disastrous  to  the  patient.  In  adnexal 
disease  the  pain  and  the  objective  findings  are  most  always  bilat- 
eral, while  in  appendicitis  they  are  unilateral  and  the  pain,  as  a 
rule,  is  more  acute.  Non-ruptured  right  tubal  pregnancy  simu- 
lates and  is  frequently  diagnosed  chronic  appendicitis.  Rigidity 
and  tenderness  over  AIcBurney's  point  are  seldom  marked  in  ex- 
tra-uterine pregnancy.  Intelligent  interpretation  of  the  clinical 
history  and  of  the  objective  findings,  furnished  by  a  careful  and 
thorough  abdominal,  rectal  and  vaginal  examination  helps  one 
to  arrive  at  a  correct  diagnosis.  Abscesses  in  the  pouch  of  Doug- 
las, due  to  perforative  appendicitis,  have  been  wrongly  attributed 
to  primary  uterine  and  tubal  infection ;  right-sided  parametritis, 
due  to  the  spreading  of  a  retro-colic  appendicitis,  has  been  diag- 
nosed ordinary  puerperal  infection. 

In  pyelitis,  uteritis,  ureteric  calculus  of  the  right  side  one  is 
guided  by  the  urinary  symptoms  and  findings.  Hepatic  colic  has 
a  sudden  onset  with  pain  in  the  right  upper  abdominal  quadrant ; 
this  pain  radiates  toward  the  right  shoulder  and  is  usually  apy- 
retic.  The  pain  of  nephritic  colic  descends  and  radiates  toward 
the  external  genitalia.  In  fecal  impaction,  the  symptoms  are  less 
severe  and  yield  to  colonic  injections  and  to  laxatives. 

In  advanced  pregnancy,  the  differential  diagnosis  between  ap- 
pendicitis and  cholecystitis  may  prove  difficult  owing  to  the  as- 
sociated upward  displacement  of  the  cecum  and  appendix  by  the 
pregnant  uterus. 

(To  be  continued.) 


106     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


SxtrartB  from  l^amt  nnh  l^otn^n  ianvnulB 


SURGICAL. 


Local  Anesthesia  in  Surgery  of  the  Colon  and  Rectum. 


Beach's  conclusions  fully  detailed  in  the  International  Clinics 
for  March  on  the  subject  are  as  follows: 

First:  Eliminating  terrorism  associated  with  operations  tnider 
general  anesthesia. 

Second :     Absence  of  postoperative  distress  and  complications. 

Third :  The  anesthesia  is  complete,  thoroughly  blocking  the 
field,  thus  preventing  shock. 

Fourth :  It  persuades  the  patient  to  undergo  an  operation  be- 
cause the  detention  from  business  is  shorter  and  postoperative 
pain  is  less. 

Fifth:  Skill  in  technic  is  achieved  by  virtue  of  the  surgeon's 
care  in  gentle  handling  of  a  conscious  patient. 

Sixth:  It  will  teach  him  to  handle  tissues  more  deftly  in  general 
anesthesia,  realizing  that  much  pain  and  tendency  to  infection 
follows  tearing  and  mutilating  of  soft  parts. 

Seventh :  Local  anesthesia  conserves  the  patient's  peace  of 
mind,  as  there  are  many  who  will  testify  to  its  efficiency  and  com- 
plete relief  with  so  little  invonvenience. — IVm.  M.  Beach. 


Treatment  of  Epithelioma  by  Radium. 


The  writer  emphasizes  the  fact  in  the  International  Clinics  with 
many  photographic  illustrations  that  in  each  case  the  proper  form 
of  radiation  and  dosage  for  each  case  must  be  carefully  deter- 
mined. 

Four  classes  of  epithelioma  are  to  be  considered : 
First:  The  lesion  which  can  be  cured  by  one  application  of  ra- 
dium with  the  proper  dosage. 


EXTRACTS  FROM  JOURNALS  107 

Second :  The  lesion  which  is  so  situated  that  glandular  involve- 
ment is  likely  to  take  place  or  has  already  occurred  and  the  roent- 
gen ray  should  be  employed  as  an  adjunct  to  treat  adjacent  glands. 

Third:  Those  cases  in  which  the  local  application  of  radium 
supplemented  by  the  roentgen  ray  will  only  act  as  a  palliative 
measure. 

Fourth :  Those  cases  in  which  excision  is  justified  to  be  fol- 
lowed by  radiotherapy. 

Professor  Boggs  believes  that  radium  and  the  X-ray  should 
always  be  considered  first  in  the  treatment  of  epithelioma,  be- 
cause, when  properly  applied,  practically  all  epitheliomatous  tis- 
sue can  be  made  to  disappear  and  there  are  fewer  recurrences 
than  by  any  other  method.  In  order  to  apply  the  method,  how- 
ever, the  operator  must  have  the  requisite  clinical  experience  with 
these  growths  as  well  as  a  knowledge  of  the  use  of  the  agents 
employed. 

Inoperable  cases  in  which  the  tonsil  is  involved  are  often  mark- 
edly improved  so  far  as  symptoms  are  considered. — Russell  H. 
Boggs. 


Syphilis  as  an  Etiological  Factor  in  Laennec's 
Atrophic  Cirrhosis  of  the  Liver. 


Symmers  in  a  study  of  atrophic  cirrhosis  of  the  liver  in  the 
•  International  Clinics  concludes  that  alcohol  plays  a  secondary  role 
in  the  etiology  of  atrophic  cirrhosis  of  the  liver.  A  certain  per- 
centage of  the  cases  conform  to  the  type  described  by  Laennec. 
In  this  group  syphilis  is  the  primary  etiological  factor,  and  alco- 
hol, if  it  enters  into  the  process  at  all,  is  contributory,  and  not 
essential. — Doiio-las  Symmers. 


'Ambrine"  Treatment  for  Burns. 


A  most  interesting  story  of  the  "ambrine"  treatment  for  burns 
received  by  soldiers  in  the  European  war  appears  in  the  New 
York  Medical  Record  of  January  27.     It  recalls  a  talk  recently 


108     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

given  in  this  city  by  Mr.  Cyril  Maud,  an  English  actor,  who 
plays  the  title  role  in  "Grumpy,"  who  stated  the  facts  as  written 
him  by  a  friend  wlho  had  seen  the  marvelous  results  accomplished 
by  this  treatment. 

Though  used  by  its  discoverer,  Dr.  Barthe  de  Sandford,  when- 
ever occasion  seemed  to  him  to  demand,  since  early  in  the  nine- 
teen hundreds,  it  was  another  case  of  "a.  prophet  is  not  without 
honor  save  in  his  own  country,"  for  it  never  until  recently  re- 
ceived the  recognition  which  it  merited.  Through  results  ob- 
tained and  the  influence  of  friends,  the  French  War  Office  has 
at  last  learned  the  worth  of  this  treatment  and  not  only  orders 
soldiers  suffering  from  burns  to  be  sent  Dr.  de  Sandford,  when 
possible,  but  has  also  established  the  treatment  in  the  front  line 
hospitals.  This  is  imperative  for  the  best  results,  as  the  cure 
is  more  of  a  success  when  received  shortly  after  the  injury.  In 
numberless  cases,  the  burns  have  not  only  been  cured,  but  the 
surfaces  restored  to  their  normal  state. 

"Ambrine"  seems  to  have  received  its  name  from  its  amber 
hue.  de  Sandford  is  said  to  have  made  its  discovery  in  an  effort 
to  find  a  home  treatment  as  a  substitute  for  the  hot  mud  bath 
treatment  for  rheumatism.  After  a  number  of  experiments,  he 
decided  upon  combining  paraffin  with  the  resin  of  amber,  which, 
when  melted  together  and  applied  hot,  made  a  firm  bandage, 
affording  relief.  Its  application  in  the  cases  of  the  war  burns 
gives  immediate  relief  from  the  agony  which  it  almost  sickens 
one  to  witness.  The  ambrine  is  applied  hot  (we  understand  at 
158  degrees  F.)  in  small  quantities.  Over  this  is  placed  a  thin 
layer  of  gauze  and  on  top  of  this  is  placed  more  ambrine.  After 
twenty-four  hours,  this  is  removed  en  masse,  and  after  treat- 
ment of  the  burnt  surface,  another  application  made.  Healing 
is  comparatively  rapid  and,  as  previously  stated,  results  are  said 
to  be  marvelous.  Cures  have  been  known  to  result  in  burns  of 
such  severity  that  death  would  under  ordinary  circumstances 
have  been  expected. — Virginia  Medical  Semi-Monthly. 


EXTRACTS  FROM  JOURNALS  109 

MEDICAL. 


The  Relation  of  the  Hypophysis  to  Certain  Clinical  Man- 
ifestations AND  the  Therapeutic  Application 
OF  the  Extracts. 


Miller  in  the  American  Journal  of  the  Medical  Sciences  for 
October,  1916,  writing  a  paper  on  this  subject,  says  that  mention 
should  be  made  of  the  use  of  posterior  lobe  extracts  in  the  treat- 
ment of  bronchial  asthma.  On  account  of  pituitrin  having  an 
effect  on  blood-pressure  "somewhat  resembling  adrenalin,  several 
publications  have  appeared  recommending  its  use  in  bronchial 
asthma.  This  is  apparently  wrong.  Pal,  Frohlich  and  Pick, 
Baehr  and  Pick,  and  others  have  shown  that  pituitrin  produces 
bronchial  spasm,  while  the  relief  given  by  adrenalin  is  due  to  its 
power  to  dilate  the  bronchi.  Baehr  and  Pick  have  also  shown 
that  when  combined  with  adrenalin  the  pituitrin  action  on  the 
bronchi  is  inhibited  by  the  adrenalin.— T/t^  Therapeutic  Gazette. 


A  New  Diagnostic  Sign  in  Typhoid  Fever. 


As  long  as  human  nature  remains  what  it  is,  says  the  Medical 
Record,  so  long  will  physicians  experience  the  temptation  to 
astonish  the  families  of  their  patients,  and  even  their  own  col- 
leagues, by  "snap"  diagnoses.  The  length,  for  example,  to  which 
diagnosis  by  the  facies  can  be  carried  is  amazing  to  the  un- 
initiated. It  is  a  matter  of  every-day  experience  for  the  doctors 
on  duty  at  Ellis  Island  to  stand  watching  immigrants  file  past 
them  by  the  thousand  and  to  pick  out  of  the  lines,  guided  solely 
by  the  expression  of  their  faces,  men  suffering  from  heart  dis- 
ease, kidney  disease,  and  even  hernia.  This  facility  can,  of  course, 
only  come  with  constant  practice,  but  there  are  many  signs  in 
ordinary  diseases  by  means  of  which  a  physician  is  often  able 
to  anticipate  the  diagnosis,  although  he  is  careful  not  to  rely 
upon  them  to  the  exclusion  of  laboratory  confirmation.     Some- 


110     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

times  these  signs,  moreover,  are  lauded  too  enthusiastically  by 
their  discoverers  as  being  pathognomonic ;  later  it  is  found  that 
they  may  occur  in  so  many  other  conditions  that  they  are  perforce 
relegated  to  the  cobwebby  limbo  of  medical  curiosities. 

Whether  or  not  such  will  be  its  fate,  a  new  sign  for  typhoid 
fever,  called  the  "crossed-hip  reflex,"  has  been  discovered  by  an 
English  physician,  Dr.  E.  B,  Gunson,  who  describes  it  in  the 
Lancet  of  September  i6,  1916,  as  follows :  "When  the  quadriceps 
femoris  muscle  mass  is  firmly  grasped  just  above  the  knee  be- 
tween the  thumb  and  fingers  the  patient  experiences  considerable 
pain  referred  to  the  site  of  stimulation,  and  there  occurs  flexion 
at  the  hip  joint  and  extension  of  the  great  toe  of  the  opposite 
limb.  The  reflex  may  be  incomplete,  and  consist  of  flexion  at 
the  hip  only  or  flexion  at  the  hip  and  contraction  of  the  tensor 
fasciae  femoris  muscle  without  actual  extension  of  the  great  toe ; 
crossed  extension  of  the  great  toe  without  flexion  at  the  hip 
occurs  in  some  cases.  Pain  on  stimulation  is  a  marked  feature, 
and  usually  persists  for  several  days  after  the  reflex  movements 
can  no  longer  be  elicited.  Similar  but  uncrossed  movements  of 
the  limb  which  is  stimulated  may  also  occur." 

The  writer,  who  had  previously  described  this  sign  as  occurring 
in  cerebral  tumor,  various  cerebrospinal  conditions,  and  diph- 
theria, studied  thirty-seven  cases  of  typhoid  fever  with  the  fol- 
lowing results :  The  complete  reflex  was  present  on  one  side  in 
four  cases  and  in  nine  other  cases  there  was  an  incomplete  re- 
sponse. In  other  words,  approximately  one-third  of  all  cases 
showed  this  reflex,  and  it  seems  to  be  pathognomonic  when  oc- 
curring, as  Gunson  never  found  it  in  doubtful  cases  which  turned 
out  later  on  to  be  simple  enteritis.  The  time  of  onset  and  duration 
of  this  sign  seemed  to  be  variable,  occurring  as  early  as  the  second 
day  and  lasting  into  the  eighth  w^ek. 

It  seems  probable  that  this  reflex  is  due  to  a  temporary  dis- 
turbance of  the  spinal  cord,  possibly  caused  by  the  toxemia,  some- 
what analogous  to  the  meningismus  often  occurring  in  the  acute 
infections  of  children.  It  should  be  sought  for  in  other  acute 
infections  before  we  place  it  definitely  in  our  diagnostic  equip- 
ment.— The  Medical  Brief. 


EXTRACTS  FROM  JOURNALS  111 

OBSTETRICAL 


Caesarean  Section:  Indications,  Technique,  and  Time  of 

Operating. 


Charles  M.  Green  (Boston  Medical  and  Surgical  Journal) 
draws  his  inferences  and  conclusions  on  this  subject  not  only 
from  the  results  of  a  previous  series  published  in  1907,  but  from 
the  work  of  the  past  eight  years,  covering  above  three  hundred 
Caesarean  sections.  In  regard  to  the  time  of  operating,  except 
in  rare  cases  such  as  cardiac,  toxemic,  and  placenta  previa  con- 
ditions, it  is  generally  best  not  to  operate  until  the  parturient  has 
been  in  labor  for  a  certain  number  of  hours,  and  he  states  the 
advantages  of  such  procedure  as  follows :  ( i )  It  is  certain  that 
the  pregnancy  has  reached  its  full  term.  Abdominal  Caesarean 
section  is  done  largely  in  the  interest  of  the  baby  in  elective 
operations,  and  it  is  a  pity  to  deprive  the  baby  of  its  last  two  or 
three  weeks  of  intrauterine  development.  (2)  There  is  greater 
certainty  that  in  the  convalescence  the  uterus  will  have  free 
drainage.  Labor  continues  naturally  until  the  cervix  is  taken 
up  and  the  os  uteri  expanded  an  inch  or  two  allows  for  free 
drainage,  and  risks  of  lochial  retention  are  avoided.  (3)  There 
is  less  bleeding  from  the  placental  site.  (4)  The  uterine  scar 
is  stronger.  Sutures  applied  to  a  wall  thickened  by  several  hours 
of  uterine  activity  allow  for  a  scar  as  strong  as,  if  not  stronger 
than,  the  remainder  of  the  uterus.  (5)  It  is  more  certain  that 
abdominal  delivery  is  really  necessary  in  the  interest  of  mother 
and  baby,  or  both,  in  the  so-called  border-line  cases.  Humility 
is  good  for  mortals,  and  it  may  as  well  be  acknowledged  that  no 
man  can  say  with  certainty  what  any  given  woman  may  do  in 
labor.  Green  outlines  twenty  cases  and  says  that  out  of  this 
number  only  one  mother  died — from  embolism — and  that  there 
was  no  fetal  loss.  From  his  present  knowledge  and  experience 
he  draws  definite  conclusions,  part  of  which  are  given  here:  (i) 
Every  pregnant  woman  should  receive  the  best  of  antepartum 
study  and  care  in  order  that  the  obstetrician  may  understand  the 


112     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

conditions  presented.  (2)  Except  under  special  conditions,  labor 
should  be  allowed  to  progress  for  a  number  of  hours.  (3)  Dur- 
ing the  observation  of  labor  vaginal  examinations  should  be 
avoided,  and  progreas  noted  by  external  and  rectal  palpation. 
(4)  Except  when  easy  access  to  the  pelvis  is  necessary,  the 
supraumbilical  incision  is  preferable.  (5)  There  is  no  reason 
for  eventration  of  the  undelivered  uterus.  (6)  Time  should 
be  taken  for  a  triple-layer  suture  of  the  abdominal  wall,  especial 
care  being  used  with  the  fascia,  which  is  best  closed  with  over- 
lapping and  mattress  stitch.  (7)  The  uterine  wall,  thickened  by 
some  hours  of  muscular  contraction,  should  be  closed  carefully 
with  deep  and  seroserous  absorbable  sutures.  (8)  The  uterus 
was  created  a  movable  organ ;  it  should  be  allowed  to  remain  so, 
at  least  in  all  married  woman,  until  after  the  climacteric. — 
Medical  Record. 


EDITORIALS  113 


lEhttoml 


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The  Tennessee  State  Medical  Society. 


This  venerable  and  time  honored  association  met  in  its  eighty- 
fourth  annual  session  in  the  Wilson  auditorium  of  the  Y.  M.  C.  A. 
April  10th,  11th  and  12th. 

This  was  doubtless  the  most  largely  attended  meeting  in  the  his- 
tory of  the  society.  According  to  the  statement  of  the  secretary 
over  four  hundred  delegates  were  registered  and  probably  over  a 
hundred  who  did  not  register  were  in  regular  attendance.  The 
meeting  was  thoroughly  enjoyable  throughout,  the  papers  pre- 
sented being  of  the  best  class  and  widely  discussed.  Enthusiasm 
of  an  unusual  degree  marked  the  different  sessions  and  every 
physician  who  attended  departed  for  home  filled  with  pleasant 
memories  of  scientific  papers  listened  to  and  old  acquaintances 
revived.  The  social  features  of  the  occasion  were  enjoyable,  and 
the  annual  banquet  at  the  Tulane  Hotel  a  great  success.  The  ex- 
hibits at  this  meeting  of  paraphernalia  belonging  to  the  physicians 
domain  were  full  of  interest  to  the  visiting  doctors.  The  patri- 
otic spirit  of  the  medical  profession  was  clearly  manifested  at  the 
banquet  where  a  number  of  speeches  professing  the  loyalty  of  the 
profession  to  the  U.  S.  government  and  its  readiness  as  expressed 
in  a  telegram  sent  to  President  Wilson  to  respond  to  any  call  the 
chief  executive  may  madke. 

The  oflficers  of  the  association  elected  on  the  third  day  of  the 
meeting  were  as  follows :  President,  E.  T.  Newell,  M.D.,  Chat- 
tanooga; Vice  President  for  East  Tennessee,  H.  M.  Cass,  M.D., 


114     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Johnson  City;  Vice  President  for  Middle  Tennessee,  T.  G.  Pol- 
lard, M.D.,  Nashville;  Vice  President  for  West  Tennessee,  W.  O. 
Sullivan,  M.D.,  Newbern;  Treasurer,  J.  F.  Gallagher,  M.D., 
Nashville;  Secretary,  Olin  West,  M.D.,  Nashville,  reelected; 
delegate  to  the  American  Medical  Association,  A.  F.  Richards,  M. 
D.,  Sparta;  alternate,  W.  B,  Burns,  M.D.,  Memphis;  councilors, 
S.  R.  Miller,  M.D.,  Knoxville;  Z.  L.  Shipley,  M.D.,  Cookeville; 
W.  C.  Dixon,  M.D.,  Nashville;  A.  B.  Dancy,  M.D.,  Jackson,  and 
W.  T.  Black,  M.D.,  Memphis.  The  next  place  of  meeting  for  its 
eighty-fifth  session  will  be  held  at  Memphis,  Tenn. 


John  Henry  Clay  Cuffman,  M.D.,  Gurdon,  Ark. ;  University  of 
Nashville,  Tenn.,  1889 ;  aged  53 ;  a  Fellow  of  the  American  Med- 
ical Association;  local  surgeon  of  the  Missouri  Pacific  System; 
President  of  the  Clark  County  Bank;  died  in  St.  Luke's  Hospital, 
Little  Rock,  Ark.,  March  18th. 


The  annual  meeting  of  Alienists  and  Neurologists  will  be  held 
Monday,  July  9th,  to  Thursday,  July  12th,  19171  in  the  Red  Room, 
LaSalle  Hotel,  Chicago,  under  the  auspices  of  the  Chicago  Med- 
ical Society.  Dr.  George  A.  Zeller  will  act  as  chairman.  The 
program  will  be  mailed  June  28th,  with  abstract  of  each  paper. 
Contributors  to  the  program  are  solicited.  This  is  a  society  with- 
out a  membership  fee.  Address,  Secretary  A.  and  N.,  Room  1218- 
30  No,  Michigan  Ave.,  Chicago.    , 


Kill  Flies  and  Save  Lives. 


Kill  at  once  every  fly  you  can  find  and  burn  his  body. 

Observers  say  that  there  are  many  reasons  to  believe  there  will 
be  more  flies  this  season  than  for  a  number  of  years. 

The  killing  of  just  one  fly  NOW  means  there  will  be  billions 
and  trillions  less  next  summer. 

Clean  up  your  premises ;  see  and  insist  that  your  neighbors  do 
likewise. 


EDITORIALS  116 

Especially  clean  "out-of-the-way  places,"  and  every  nook  and 
cranny. 

Flies  will  not  go  where  there  is  nothing  to  eat,  and  their  prin- 
cipal diet  is  too  filthy  to  mention. 

The  fly  is  the  tie  that  binds  the  unhealthy  to  the  healthy! 

The  fly  has  no  equal  as  a  germ  "carrier" ;  as  many  as  five  hun- 
dred million  germs  have  been  found  in  and  on  the  body  of  a 
single  fly. 

It  is  definitely  known  that  the  fly  is  the  "carrier"  of  the  germs 
of  typhoid  fever;  it  is  widely  believed  that  it  is  also  the  "carrier" 
of  other  diseases,  including  possibly  infantile  paralysis. 

The  very  presence  of  a"  fly  is  a  signal  and  notification  that  a 
housekeeper  is  uncleanly  and  inefficient. 

Do  not  wait  until  the  insects  begin  to  pester;  anticipate  the 
annoyance. 

April,  May  and  June  are  the  best  months  to  conduct  an  anti-fly 
campaign. 

The  farming  and  suburban  districts  provide  ideal  breeding 
places,  and  the  new  born  flies  do  not  remain  at  their  birth  place 
but  migrate,  using  railroads  and  other  means  of  transportation, 
to  towns  and  cities. 

Kill  flies  and  save  lives ! 

Edward  Hatch,  Jr.  Chairman ;  John  Y.  Culyer,  Daniel  D.  Jack- 
son, Dr.  Albert  Vander  Veer,  Committee.    April,  1917. 


Announcement. 
Association  of  Medical  Officers  of  the  Army  and  Navy  of  the 
Confederate  States. 


The  twentieth  annual  meeting  of  the  Association  of  Medical 
Officers  of  the  Army  and  Navy  of  the  Confederate  States  will  be 
held  in  the  New  Willard  Hotel,  headquarters  of  the  United  Con- 
federate Veterans,  Washington,  D.  C,  June  4,  5,  6,  7,   8,  1917. 

All  those  who  were  surgeons,  assistant  surgeons,  or  acting  as- 
sistant surgeons  and  chaplains  of  the  Confederate  army  or  navy, 
and  all  those  who  served  in  the  army  or  the  navy  as  soldiers  or 


116     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

sailors — not  then  medical  officers — but  who,  after  the  war,  be- 
came regular  practitioners  of  medicine  in  good  standing;  and  all 
regular  practitioners  of  medicine  whose  fathers  or  grandfathers 
served  in  the  Confederate  army  or  navy  are  eligible  to  full  mem- 
bership. 

And  all  those  who  served  as  matrons  or  nurses  in  the  hospitals 
or  in  the  field  are  welcomed  to  honorary  membership. 

The  objects  of  the  association  are  to  collect  all  official  records 
and  important  facts,  as.  far  as  may  be  possible,  relating  to  the 
history  of  the  medical  departments  of  the  army  and  navy  of  the 
Confederate  States;  to  ascertain  the  military  records  of  all  the 
officers  and  prepare  a  roster  of  the  same ;  to  honor  the  memory  of 
its  deceased  members,  and  the  memory  of  the  nurses ;  and  other- 
wise, not  already  mentioned,  to  perpetuate  the  history  of  said 
departments  and  of  this  association. 

Further  information  will  be  supplied  upon  application  to  the 
Secretary. 

(Signed)  Carroll  Kendrick,  M.D.,  President,  Kendrick,  Miss. 
Official:  Samuel  E.  Lewis,  M.D.,  Secretary,  1418  14th  Street, 
N.  W.,  Washington,  D.  C.    March  15,  1917. 


Medical  Interne. 
St.  Elizabeths  Hospital,  June  6,  1917. 


The  United  States  Civil  Service  Commission  announces  an  open 
competitive  examination  for  medical  interne,  for  both  men  and 
women,  on  June  6,  1917,  at  the  places  mentioned  in  the  list  printed 
hereon.  A  vacancy  in  St.  Elizabeths  Hospital,  Washington,  D. 
C,  at  $900  a  year,  with  maintenance,  and  future  vacancies  requir- 
ing similar  qualifications  will  be  filled  from  this  examination,  un- 
less it  is  found  in  the  interest  of  the  service  to  fill  any  vacancy  by 
reinstatement,  transfer,  or  promotion. 

Male  eligibles  are  desired  for  the  existing  vacancy. 

The  positions  are  tenable  for  one  year,  and  pay  $75  a  month  and 
maintenance.  During  the  year,  however,  a  postgraduate  course 
in  mental  and  neurological  diagnostic  methods  is  given,  an  exam- 


EDITORIALS  117 

ination  is  held,  and  promotions  to  the  next  grade,  junior  assistant 
physician,  are  made.  Beyond  this  there  is  regular  advancement 
for  men  whose  services  are  satisfactory.  St.  EHzabeths  Hospital 
has  over  3,000  patients  and  about  800  employes  to  care  for.  In 
addition  to  the  general  medical  practice  offered,  the  scientific  op- 
portunities in  neurology  and  psychiatry  are  unsurpassed. 

Competitors  will  be  examined  in  the  following  subjects,  which 
will  have  the  relative  weights  indicated: 

Subjects  Weights 

1.  Anatomy  and  physiology  (general  questions  on  anatomy 

and  physiology,  and  histology  or  minute  anatomy 10 

2.  Chemistry,  materia  medica,  and  therapeutics   (elemen- 

tary questions  in  inorganic  and  organic  chemistry,  the 
physiologic  action  and  therapeutic  uses  and  doses  of 
drugs)    15 

3.  Surgery  and  surgical  pathology   (general  surgery,  sur- 

gical diagnosis,  the  pathology  of  surgical  diseases) __     20 

4.  General  pathology  and  practice   (the  symptomatology, 

etiology,  diagnosis,  pathology,  and  treatment  of  dis- 
eases)        25 

5.  Bacteriology  and  hygiene  (bacteriologic  methods,  espe- 

cially those  relating  to  diagnosis ;  the  application  of 
hygienic  methods  to  prophylaxis  and  treatment 15 

6.  Obstetrics  and  gynecology  (the  general  practice  of  ob- 

stetrics, diseases  of  women,  their  pathology,  diagni- 
sis,  symptoms,  and  treatment,  medical  and  surgical-     15 


Total 100 

Applicants  must  show  that  they  are  graduates  of  a  reputable 
medical  college  or  that  they  are  senior  students  in  such  an  insti- 
tution and  expect  to  graduate  within  six  months  from  the  date 
of  this  examination.  The  names  of  senior  students  will  not  be 
certified  for  appointment  in  the  event  they  attain  eligibility  in  the 
examination  until  they  have  furnished  proof  of  actual  graduation. 

Applicants  must  not  have  graduated  previous  to  the  year  1915 
unless  they  have  been  continuously  engaged  in  hospital,  laboratory 


118     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

or  research  work  along  the  Hnes  of  neurology  or  psychiatry  since 
graduation,  which  fact  must  be  specifically  shown  in  the  appli- 
cation. 

Applicants  must  be  unmarried. 

Age,  20  years  or  over  on  the  date  of  the  examination. 

No  sample  questions  of  this  examination  will  be  furnished. 

Applicants  must  submit  to  the  examiner  on  the  day  of  the  ex- 
amination their  photographs,  taken  within  two  years,  securely 
pasted  in  the  space  provided  on  the  admission  cards  sent  them 
after  their  applications  are  filed.  Tintypes  or  proofs  will  not  be 
accepted. 

This  examination  is  open  to  all  citizens  of  the  United  States 
who  meet  the  requirements. 

AppHcants  should  at  once  apply  for  Form  1312,  stating  the  title 
of  the  examination  desired,  to  the  Civil  Service  Commission, 
Washington,  D.  C,  or  to  the  secretary  of  the  United  States  Civil 
Service  Board  at  any  place  mentioned  in  the  list  printed  hereon. 
Applications  should  be  properly  executed,  excluding  the  medical 
and  county  officer's  certificates,  and  filed  with  the  Commission  at 
Washington  in  time  to  arrange  for  the  examination  at  the  place 
selected  by  the  applicant.  The  exact  title  of  the  examination  as 
given  at  the  head  of  this  announcement  should  be  stated  in  the 
application. 

Issued  April  2,  1917. 


"He  died  of  typhoid  fever  on  the  14th  of  December,  1861." 
To  be  the  consort  of  a  queen,  to  be  beloved  by  her  people,  both 
high  and  low,  to  be  the  real  but  unobserved  adviser  of  the  afifairs 
of  an  empire,  these  are  achievements  worth  while.  To  be  cut  off 
from  all  of  them  at  the  prime  age  of  42  by  a  wholly  preventable 
disease  seems  wanton.  "The  good  Prince"  Albert,  consort  of 
Queen  Victoria,  patron  of  the  arts  and  sciences,  a  skillful  admin- 
istrator and  an  upright  man  was  sacrificed  to  a  filth  disease. 

Typhoid  fever  is  found  only  in  man.  It  is  caused  by  a  short 
rod-shaped  microscopic  vegetable,  which  enters  the  body  through 
the  mouth  and  leaves  in  it  human  discharges  to  enter  another 


EDITORIALS  119 

human  mouth  to  which  it  is  carried  by  fingers,  fiies,  fluids  and 
food.  It  is  essentially  a  disease  of  young  adult  life.  Older  peo- 
ple are  less  apt  to  have  it  probably  because  they  have  suffered 
from  an  attack  of  the  disease  in  their  youth. 

Typhoid  fever  is  known  by  various  names,  "slow  fever,"  "low 
fever,"  but  whatever  name  it  is  called  by  it  kills  about  8%  ot 
those  whom  it  attacks.  A  certain  percentage  of  those  who  re- 
cover become  carriers,  that  is,  persons  who  though  well  excrete 
the  organisms  of  the  disease  in  their  discharges.  Carriers  are 
largely  responsible  for  the  perpetuation  of  typhoid  fever,  but  the 
installation  of  proper  sewer  systems  which  not  only  take  away 
noxious  wastes  but  also  "do  not  deposit  them  in  some  one  elses 
water  supply,  the  abolition  of  flies,  cockroaches,  and  other  filth 
insects,  the  maintenance  of  a  pure  food  supply,  and  the  intelligent 
care  of  the  typhoid  patient,  these  are  the  measures  which  will  rid 
us  from  this  disease.  Until  very  recently  typhoid  has  been  the 
scourge  of  armies  but  now  the  anti-typhoid  inoculation  has  re- 
duced this  danger  to  a  minimum. 

The  Prince-Consort  was  universally  mourned.  The  grief  of 
the  queen  was  deep  and  lasting  and  the  whole  nation  sympathized 
in  the  truest  sense  with  her  in  her  sorrow.  How  many  widows 
of  less  exalted  position  mourn  also  because  of  the  rapacity  of 
typhoid  fever? 


Notice  to  Advertisers. 


While  we  gladly  give  space  to  reading  notices  in  our  regular 
issues  we  must  ask  that  such  notices  be  abridged  as  much  as  pos- 
sible hereafter  as  we  have  been  compelled,  by  increased  costs  of 
publication,  to  reduce  the  size  of  the  Journal  by  twelve  pages. 


120     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

VitintbxB  ntdi  Hack  NotirrB 


Clinical  and  Laboratory  Technic — By  H.  L.  McNeil,  A.B.,  M.D.,  Adjunct 
Professor  of  Medicine  and  Instructor  in  Physical  Diagnosis,  University 
of  Texas  Medical  School,  Galveston,  Texas.  Illustrated.  St.  Louis. 
C.  V.  Mosby  Company.     1916. 

This  little  book  was  prepared  especially  for  hospital  internes 
and  advanced  students  to  assist  them  in  their  laboratory  work  and 
clinical  tests  and  as  sucli  will  be  found  a  most  valuable  hand- 
book. It  will  also  prove  of  value  to  the  general  practitioner  who 
does  some  of  the  laboratory  tests  himself.  The  author  pays  par- 
ticular attention  to  the  trial  of  history  taking,  physical  diagnosis 
and  laboratory  analysis,  and  while  he  does  not  claim  anything  in 
the  work  different  from  that  found  in  other  books,  he  insists  that 
only  practical  details  are  given  and  theoretical  considerations,  en- 
tirely omitted.  It  is  fully  illustrated  and  systematically  arranged. 
We  do  not  hesitate  to  say  that  the  little  book  will  be  found  of  the 
greatest  value  to  everyone  interested  in  careful  scientific  diag- 
nostic methods. 


Practical  Uranalyses— By  B.  G.  R.  Williams,  M.D.,  Director  Wabash  Val- 
ley Research  Laboratory.  Author  of  Laboratory  Methods,  etc.  Illus- 
trated.    St.  Louis.     C.  V.  Mosby  Company.     1916. 

This  is  another  useful  vade  mecum  issued  from  the  press  of 
C.  V.  Mosby  Company  of  St.  Louis.  Examination  of  the  urine 
is  an  essential  requirement  of  every  diagnostic  examination.  To 
our  mind  this  little  book  is  of  the  greatest  value  to  students  and 
practitioners  who  desires  to  become  familiarized  with  this  im- 
portant aid  to  diagnosis.  Six  chapters  make  up  the  book.  Chap- 
ter I,  Properties  of  the  Normal  Urine.  Chapter  2,  General  Uran- 
alysis.  Chapter  III,  Chemical  Uranalysis.  Chapter  IV,  Quanti- 
tative Uranalysis.  Chapter  V,  Microscopic  Uranalysis.  Chapter 
VI,  Bacteriological  Uranalysis. 

From  this  table  of  contents  our  readers  can  obtain  an  idea  of 
the  makeup  of  the  little  book.  We  are  pleased  with  the  manual 
and  take  pleasure  in  recommending  it  to  the  profession. 


REVIEWS  AND  BOOK  NOTICES  121 

A  Journey  Around  the  World  by  an  Oculist — By  Flavel  B.  Tiffany,  A.M., 
M.D.,  Kansas  City,  Mo.  Franklin-Hudson  Publishing  Company,  Kansas 
City,  Mo.     1917.     Price  $2.00. 

We  have  been  greatly  interested  in  the  letters  from  Dr.  Tiffany, 
published  regularly  in  the  Medical  Fortnightly,  giving  brief  but 
delightfully  clear  descriptions  of  the  distinguished  oculists  visits 
to  the  most  important  doctors,  especially  oculists  in  various  for- 
eign countries.  These  letters  we  are  pleased  to  state  are  to  be 
published  in  book  form  and  as  such  will  prove  of  great  interest, 
not  only  to  the  general  public,  but  also  to  the  specialists  in  this 
branch  of  surgery.  The  book  will  be  profusely  illustrated  and 
the  text  will  be  written  in  the  peculiarly  attractive  manner  of  the 
author  so  that  it  will  prove  of  the  greatest  interest  to  the  reader. 
We  trust  doctors  will  avail  themselves  of  seeing  the  world  in  this 
book  through  the  eyes  of  an  oculist. 


Cataract — Senile,  Traumatic  and  Congenital — By  W.  A.  Fisher,  M.D.,  Pro- 
fessor of  Ophthalmology,  Chicago  Eye,  Ear,  Nose  and  Throat  College, 
Chicago.  Published  by  Chicago  Eye,  Ear,  Nose  and  Throat  College. 
1917. 

We  are  indebted  to  the  author  for  a  copy  of  this  exceedingly 
interesting  and  practically  instructive  book.  The  six  points  the 
author  endeavors  to  emphasize  are : 

First:  A  new  method  of  acquiring  operative  technique  upon 
the  eye-ball  with  the  aid  of  four  weeks'  old  kittens. 

Second:  Discarding  all  kinds  of  eye  specula  and  holding  the 
lids  away  from  the  eyeball  when  operating  or  dressing  the  eye 
after  injuries. 

Third :    Dressing  and  treatment  after  cataract  operations. 

Fourth :  A  modification  of  the  Smith-Indian  operation  for 
cataract,  making  the  removal  of  the  lens  in  capsule  safe  and  neces- 
sarily the  operation  of  choice. 

Fifth:  A  method  of  treating  injuries  of  the  lens  other  than 
watchful  waiting. 

Sixth :  A  systematic  procedure  for  determining  the  treatment 
of  congenital  cataract. 


122     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

The  features  of  this  book  as  shown  by  these  points  indicates  the 
advanced  methods  of  treatment  advocated  and  the  improved  tech- 
nique demonstrated  in  the  operative  treatment  of  this  distressing 
condition.  We  feel  sure  that  the  Httle  book  will  be  well  received 
by  the  profession  and  that  it  will  prove  of  inestimable  value  to  all 
interested  in  this  branch  of  surgery.  The  book  is  illustrated  co- 
piously by  clear  and  readily  interpreted  illustrations. 


PUBLISHERS'  DEPARTMENT  123 


PuhUaI|?r*0  i^partmrnt 


The  Wider  Use  of  the  Bromides. 


The  great  utility  of  the  bromides  when  intelligently  used,  is  not 
half  appreciated  by  the  average  practitioner.  To  be  sure,  medical 
men  do  not  employ  the  bromides  for  many  conditions,  but  to  no- 
where near  the  extent  that  they  could.  It  is  a  mistaken  idea  that 
bromides  are  serviceable  only  for  the  treatment  of  nervous  dis- 
eases. It  is  true,  their  effects  may  be  accomplished  primarily  by 
their  action  on  the  nervous  system,  but  when  we  stop  to  think  of 
the  essential  part  played  by  nervous  factors  in  the  maintenance 
of  vaso-motor  equilibrium,  secretory  activity,  nutrition  and  so  on, 
the  service  that  the  bromides  can  be  called  on  to  render  in  a  wide 
variety  of  abnormal  conditions  can  readily  be  seen. 

Obviously,  too  great  care  can  not  be  exercised  in  selecting  the 
bromide  salts  to  be  used,  particularly  in  respect  to  their  purity  and 
quality.  Probably  one  of  the  main  reasons  why  the  bromides 
have  not  been  more  generally  employed  is  the  indifferent  quality 
and  impurities  which  have  characterized  so  large  a  portion  of  the 
available  bromide  preparations. 

Those  who  have  used  Peacock's  Bromides,  however,  have  been 
able  to  employ  the  full  advantages  of  this  class  of  drugs.  Made 
from  the  purest  and  highest  grade  of  salts,  and  combined  with 
every  care  and  skill,  Peacock's  Bromides  have  assured  the  highest 
therapeutic  efficiency  with  gratifying  freedom  from  all  objec- 
tionable or  unpleasant  effect.  As  a  consequence,  the  range  of  use 
of  this  reliable  bromide  preparation  has  been  surprising,  even  to 
those  most  familiar  with  the  possibilities  of  bromide  treatment. 
Many  affections  characterized  by  congestion,  or  having  their  or- 
igin in  nervous  irritation  and  the  resulting  spasmodic  conditions, 
have  responded  to  Peacock's  Bromides  when  other  measures  have 
proven  useless.  So  with  spasmodic  disorders  of  the  intestines; 
many    conditions    that  have  seemed    organic  in  character    and 


124     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

doomed  to  operation,  have  been  properly  corrected  by  liberal  doses 
of  Peacock's  Bromides. 

Many  other  instances  showing  the  utility  of  this  remedy  could 
be  cited,  but  lack  of  space  forbids.  Suffice  it  to  say  that  there  is 
hardly  any  remedy  at  the  physician's  command  with  a  broader 
field  of  usefulness.  To  be  able  to  use  Peacock's  Bromides  in  ade- 
quate dosage  and  for  requisite  periods  of  time,  with  complete  ab- 
sence of  deleterious  effect  has  undoubtedly  been  more  or  less  re- 
sponsible for  the  foregoing,  but  the  fundamental  fact  is  that  the 
bromides  in  the  form  of  Peacock's  Bromides  have  a  much  more 
extensive  field  of  successful  application  than  is  realized. 


Rational  Treatment  of  Bowel  Inertia. 


There  is  probably  no  one  class  of  drugs  that  has  been  subject 
to  such  great  abuse  as  the  laxatives.  So  routinely  and  promis- 
cously  have  remedies  to  increase  bowel  activity  been  prescribed 
that  the  American  people  have  been  dubbed  a  "nation  of  physic 
devotees." 

It  is  indeed  unfortunate  that  cathartics  and  laxatives  have  been 
thus  employed  with  so  little  "rhyme  or  reason."  The  harm  that 
has  been  done  is  only  too  apparent  in  the  countless  sufferers  who 
never  have  a  natural  bowel  evacuation. 

Happily  a  good  many  physicians  are  awakening  to  the  desir- 
ability of  directing  their  treatment  of  bowel  inertia  and  torpidity 
toward  rational  stimulation  of  the  physiologic  functions  of  the  in- 
testinal tract.  The  results  obtained  point  so  conclusively  to  the 
wisdom  of  this  line  of  treatment  that  the  older  measures  which 
depend  for  their  effects  on  irritation  of  the  intestinal  mucosa  or 
nervous  mechanism  of  the  bowel,  or  both,  are  rapidly  becoming 
obsolete. 

Among  the  remedies  that  act  by  correcting  insufficiency  of  the 
physiologic  processes  of  the  bowels,  Prunoids  undoubtedly  enjoy 
greatest  popularity.  The  action  of  this  true  activator  of  intestinal 
functions  is  prompt  and  decided,  but  what  is  especially  note- 
worthy, this  action  of  this  true  activator  of  intestinal  functions 


PUBLISHERS'  DEPARTMENT  126 

is  prompt  and  decided,  but  what  is  especially  noteworthy,  this 
action  is  without  griping  or  any  other  disagreeable  effects.  Re- 
actionary constipation  does  not  follow,  and  unlike  so  many  other 
laxative  measures,  Prunoids  do  not  require  continuous  use  in  con- 
stantly increasing  dosage.  In  fact,  owing  to  the  effect  of  Pru- 
noids on  the  fecal  mass,  whereby  shrinkage  in  size  and  loss  of 
moisture  are  prevented,  the  physical  conditions  which  promote 
and  favor  intestinal  peristalsis  are  promptly  restored.  As  a  con- 
sequence, the  functional  activity  of  the  bowels  produced  by  Pru- 
noids shows  remarkable  persistence,  and  a  dose  on  two  or  three 
consecutive  nights  is  often  followed  by  evacuations  of  a  most 
satisfying  character  for  "several  days. 

•  It  is  this  tendency  of  Prunoids — not  only  to  produce  one  or 
more  movements  following  each  dose,  but  to  promote  physiologic 
regularity  of  the  bowels — that  makes  this  remedy  so  much  supe- 
rior to  "salts,"  or  the  laxative  measures  commonly  employed.  In 
simple  words,  the  use  of  Prunoids  means  the  rational  treatment 
of  bowel  inertia — the  activation  of  physiologic  functions. 


In  Children  and  in  Old  People. 


Kidneys  are  often  affected  by  exposure  to  cold  or  chill.  These 
disturbances  may  range  from  sudden  and  frequent  desire  to  uri- 
nate to  the  severe  forms  of  urinary  irritation.  The  first  is  usually 
accompanied  with  free  and  excessive  flow  of  water,  where  in  the 
latter  case  there  will  be  but  a  small  quantity  of  water,  frequently 
passed  with  difficulty  and  pain.  If  the  cause  is  not  removed,  this 
dysuria  wath  frequency  may  continue  day  and  night  until  cystitis 
occurs,  or  until  a  spastic  renal  condition  is  found  to  be  present, 
with  active  congestion  followed  quickly  by  acute  inflammation. 
The  remedy  is  heat  persistently  applied  externally  to  produce  re- 
laxation and  sanmetto  in  drachm  doses  for  adults  every  hour  until 
relief,  then  less  often  as  indicated,  and  half  doses  for  child  in  like 
manner.  Particularly  is  it  true  with  men  suffering  from  prostatic 
trouble  that  they  are  often  affected  by  exposure  to  cold  or  chill, 
causing  congestion  at  the  bladder  neck,  with  frequent  desire  to 


126     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

urinate,  and  urine  passed  with  difficulty  and  pain.  Hot  applica- 
tions externally,  either  moist  or  dry,  and  sanmetto  in  teaspoonful 
doses  every  hour  until  relief,  is  the  remedy. 


ECTHOL    AND    INFECTIONS, 


It  has  been  shown  that  Ecthol  (Battle)  has  a  distinctive  value 
in  infection,  and  with  many  physicians  its  employment  in  both 
local  and  systemic  infections  is  a  routine  practice.  While  this 
clinical  fact  is  easily  determined,  the  actual  modus  operandi  of 
this  agent  within  the  tissues  is  not  so  easily  understood,  but  it 
seems  logical  to  assume  that  it  increases  the  phagocytic  power 
of  the  blood  stream,  thereby  enabling  the  system  to  overcome  the 
assault  of  the  infectious  organism.  In  systemic  infections  Ecthol 
(Battle)  is  administered  internally  throughout  the  patient's  wak- 
ing period,  and  in  local  infections  with  suppurative  manifestations 
direct  applications  of  it  are  made. 


In  Functional  Nervous  Diseases. 


The  first  and  fundamental  question  which  the  earnest  physician 
asks  today  in  determining  the  utility  of  any  remedy  he  wishes  to 
use  is  "what  will  it  accomplish?"  If  it  does  what  he  asks  it  to 
do,  and  does  it  better  than  anything  else  he  has  ever  employed,  he 
wil  Icertainly  use  it  in  preference  to  anything  else.  If  it  fails  and 
proves  valueless,  he  will  as  certainly  discard  it  in  short  order.  His 
common  sense  and  intelligence  will  permit  of  no  other  course,  for 
medical  men  build  their  practices  on  successes,  not  on  failures. 
Beneficial  results  of  a  definite,  positive  character  are  constantly 
sought  and  it  is  in  achieving  these  that  a  physician  proves  his 
worth  as  a  practitioner  of  medicine.  Thus  in  the  treatment  of 
functional  nervous  diseases  derangement  of  the  bodily  nutrition 
is  so  prominent  a  factor  that  the  first  consideration  in  these  affec- 
tions is  a  restoration  of  the  nutritional  balance.  To  accomplish 
this,  Gray's  Glycerine  Tonic  Comp.  is  widely  recognized  as  a  rem- 
edy of  remarkable  efficiency.     Under  its  systematic  use  the  ap- 


PUBLISHERS'  DEPARTMENT  127 

petite  is  increased,  the  digestion  is  improved  and  the  nutrition 
shows  a  marked  and  substantial  gain.  Coincident  with  this  nutri- 
tional gain  there  is  a  corresponding  increase  in  nerve  force  with  a 
very  pronounced  and  gratifying  correction  of  insomnia,  indiges- 
tion, headaches,  vague  pains,  nervousness  and  other  symptoms  of 
nervous  origin. 

If  you  have  some  case  of  neurasthenia  or  other  functional  ner- 
vous disease  and  would  like  to  give  Gray's  Glycerine  Tonic  a  criti- 
cal trial  why  not  send  today  for  samples?  A  supply  will  be  sent 
you  at  once.  Address  the  Purdue  Frederick  Co.,  135  Christopher 
St.,  New^  York. 


"I  am  pleased  to  inform  you  that  I  have  had  wonderful  success 
with  Tongaline  during  our  epidemic  of  grippe  here  in  Boston." 

"I  have  used  Tongaline  for  more  than  twenty  years  and  have 
found  it  most  satisfactory  in  every  way.  A  very  recent  case 
which  came  under  my  care  was  one  in  which  several  physicians 
had  failed,  even  with  the  use  or  organo-therapy.  Within  forty- 
eight  hours  after  Tongaline  had  been  administered  there  was  a 
decided  remission  of  temperature  and  pain,  and  at  the  end  of  one 
month  the  patient,  who  was  a  lady  about  seventy  years  of  age, 
and  had  been  a  suffered  for  years,  was  able  to  go  about  her  room 
and  to  comb  her  own  hair,  something  which  she  had  not  done  for 
six  months  previously." 


Chronic  Constipation  of  Women. 


In  the  treatment  of  this  condition,  wdiat  the  physician  may  ex- 
pect INTEROL  to  do  is  the  following: 

(1)  It  keeps  the  feces  from  becoming  dried  and  hard.  That 
is,  it  keeps  them  soft  and  plastic;  (2)  and  in  addition,  by  lubri- 
cating them,  it  (3)  enables  them  to  squeeze  or  slip  through  angu- 
lations, convultions  and  constrictions  of  a  crowded  gut;  (4)  at 
the  same  time,  there  is  a  protective  action  to  any  raw  or  abraded 
spots. 


128     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

By  doing  these  things,  INTEROL  relieves  fecal  pressure  and 
gaseous  distention,  so  that  the  autotoxic  as  well  as  nervous  symp- 
toms are  likely  to  be  reached. 

All  these  it  does  effectively  and  harmlessly.  Its  use  does  not 
prevent  the  adjunctory  use  of  any  orthopaedic,  surgical  or  other 
procedure  that  may  be  indicated.  On  the  contrary,  INTEROL 
itself  is  more  an  adjunct  to  such  other  measures. 

INTEROL  is  unquestionably  all  that  it  is  claimed  to  be— a  val- 
uable "dietetic  accessory."  There  is  no  other  accessory  measure 
that  will  better  accomplish  what  INTEROL  does  accompHsh  in 
cases  where  it  can  accomplish  it. 

DOSAGE  is  usually  a  tablespoonful  morning  and  night  on  an 
empty  stomach,  although  this  varies  with  the  individual  pecdliar- 
ities.* 


*Booklet  and  samples  to  physicians.    Van  Horn  &  Sawtell,  15-17  E.  40th 
St.,  New  York. 


NASHVILLE  JOURNAL 

OF 

MEDICINE  AND    SURGERY 


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


Vol.  CXI.  MAY,  1917.  No.  S 


Original  QlnmmumrattnnH 


APPENDICITIS  COMPLICATING  PREGNANCY. 


BY  AIME  PAUL  HEINECK,   M.D., 

Professor  of  Surgery,  Chicago  College  of  ^Medicine  and 
Surgery,  Chicago. 


(Concluded  from  last  month.) 

PROGNOSIS. 

Pregnancy  increases  the  severity  and  the  fatality  of  appendi- 
citis. Death  may  be  due  to  intestinal  obstruction,  to  perforation 
of  the  appendix,  to  heart  failure,  to  peritonitis,  or  to  sepsis.  Re- 
covery takes  place  through  the  gradual  subsidence  of  symptoms; 
through  the  spontaneous  rupture  of  an  appendicular  abscess  ex- 
ternally, or  into  the  gut,  vagina,  urinary  bladder,  uterus,  or  other 
hollow  viscus. 

The  type  and  the  acuity  of  the  inflammation  influence  the  prog- 
nosis. The  prognosis  is  good  if  the  changes  in  the  appendix  are 
slight,  if  the  inflammation  is  limited  to  the  appendiceal  wall;  if 
there  be  slight  or  no  peritoneal  involvement,  if  complications  be 
absent.  It  is  grave  in  gangrenous,  perforative  and  suppurative 
appendicitis  and  in  all  cases  complicated  by  abscess   formation, 


130     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

near  or  distal,  or  by  diffuse  peritonitis.  The  results  for  the 
mother  and  fetus  are  better  the  less  advanced  the  gestation,  the 
less  virulent  and  widespread  the  inflammation,  the  earlier  the 
operation.  Maternal  mortality  of  appendicitis  in  pregnancy  in- 
creases from  the  fourth  month  on. 

As  far  as  the  child  is  concerned,  prognosis  is  absolutely  good 
in  cases  of  early  operated  appendicitis.  Severe  maternal  appen- 
dicitis is  exceptionally  grave  for  the  fetus,  who  succumbs  either 
through  infection  or  through  interruption  of  pregnancy.  In  our 
cases,  there  were  fifty-eight  abortions;  of  these,  nine  were  in- 
duced and  forty-nine  were  spontaneous.  The  spontaneous  abor- 
tions gave  seventeen  maternal  deaths  and  thirty-two  recoveries. 
The  induced  abortion  gave  four  maternal  deaths  and  five  recov- 
eries. 

PROPHYLAXIS. 

The  cause  of  appendicitis  is  not  known.  Therefore,  in  the 
present  state  of  our  knowledge  a  discussion  of  the  prophylaxis 
of  appendicitis,  of  necessity,  must  be  and  is  incomplete,  inadequate 
and  inconclusive.  The  importance  of  constipation  as  an  etiolog- 
ical factor  in  appendicitis  is  as  yet  undetermined.  We  do  not 
know  how  to  prevent  appendicitis,  but  we  do  know  how  to  lessen 
its  morbidity  and  mortality.  Some  surgeons  remove  the  appen- 
dix during  the  course  of  all  laporotomies.  The  removal  of  a 
healthy  organ  because  one  is  not  certain  that  it  will  always  re- 
main free  of  disease  is  unnecessary,  meddlesome,  and  contrary  to 
the  teachings  of  conservative  surgery. 

In  all  laparotomies  for  conditions  other  than  appendicitis,  if 
the  patient's  condition  permits,  the  appendix  should  be  examined 
and  removed,  1.  If  it  be  abnormal  in  length,  size  or  location.  2. 
If  it  be  in  close  relation  to  a  pedicle  or  denuded  surface,  left  by 
operation.  3.  If  its  cavity  be  partly  or  wholly  obliterated.  4. 
If  it  be  the  seat  of  anatomic  alterations,  club-shaped,  thickened, 
kinked,  twisted,  strictured,  etc.  5.  If  it  contains  foreign  bodies, 
fecal  concretions,  worms,  etc.  If  it  be  adherent,  in  part  or  in  its 
entirety,  to  some  normal  or  diseased  contiguous  organ  or  to  the 
abdominal  parietes.    7.  If  it  be  the  sole  content  or  one  of  the  con- 


ORIGINAL  COMMUNICATIONS  131 

tents  of  a  hernial  sac.    8.  If  it  be  the  seat  of  cystic,  neoplastic  or 
inflammatory  disease. 

Operations  that  contribute  to  the  safety  of  a  pregnant  woman 
should  be  performed  without  hesitation. 

INDICATIONS    FOR    OPERATION. 

Clinical  cures  obtained  by  medicinal  measures  are  rarely  ana- 
tomical cures.  Starvation  treatment  is  debilitating  to  the  mother, 
is  unfavorable  to  fetal  growth.  Perforation,  abscess,  general  peri- 
tonitis, subdiaphragmatic  abscess,  thrombosis  and  embolism  are 
possible  results  of  expe-ctant  treatment.  Better  to  remove  too 
many  appendices  than  too  few.  Be  not  deterred  by  the  possibility 
of  a  difficult  operation  for  the  results  of  early  operation  are  satis- 
factory and  the  mortality  low. 

Operate  early  in  the  attack  and  early  in  the  course  of  pregnancy. 
As  a  general  proposition,  operation  does  not  interrupt  pregnancy. 
The  triumphs  of  ovariotomy  and  hysterectomy  in  pregnancy  are 
well  known;  in  appendicitis  operation  is  even  more  urgent.  Ac- 
cumulated instances  are  on  record  in  which  pregnant  uteri  have 
been  operated  upon,  cauterized,  etc.,  in  which  ovarian  and  other 
pelvic  tumors  have  been  removed  without  pregnancy  being  ter- 
minated. The  high  mortality  of  appendicitis  in  pregnant  women 
is  due  to  fatal  temporization.  Placental,  uterine  and  peritoneal 
infections  are  such  serious  complications  that  one  should,  if  pos- 
sible, operate  before  the  inflammatory  process  has  extended  be- 
yond the  appendical  wall,  before  abscess  formation  has  taken 
place,  before  the  onset  of  peritoneal  or  other  complications. 

Operate  early  in  gestation.  At  that  period  the  uterus  is  not 
large  enough  to  be  in  the  way.  The  operation  is  less  difficult ;  the 
tendency  to  the  interruption  of  pregnancy  is  minimal  and  the 
percentage  of  maternal  recoveries  is  higher.  The  danger  of  re- 
currence in  the  latter  months  of  gestation  calls  for  operation  dur- 
ing the  attack;  if  that  be  not  feasible  an  interval  operation  should 
be  performed  as  long  before  the  labor  as  possible. 

Operation  in  fifty  cases  of  non-perforative  appendicitis  gave 
only  one  maternal  death  and  seven  abortions.  In  fifty-five  cases 
of  diflfuse  peritonitis  secondary  to  appendicitis,  there  were  forty- 


132     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

four  maternal  deaths,  only  one  child  was  saved,  all  the  others 
were  born  prematurely  or  died  soon  after  birth  from  weakness, 
or  the  illness  of  the  mother  resulted  fatally  before  the  termina- 
tion of  labor. 

TREATMENT. 

Interruption  of  pregnancy  is  not  indicated;  it  increases  the 
danger.  Rest  should  be  enjoined ;  during  the  operation,  the  uterus 
should  be  handled  and  exposed  as  little  as  possible;  after  the  op- 
eration, opiates  should  be  administered.  In  a  clean  case,  the  op- 
erative manipulation  is  slight.  Artificial  evacuation  of  the  uterus 
before  laparotomy  is  indicated  only  when  the  child  is  dead  or 
when  there  are  appreciable  signs  of  labor.  If  the  uterus  be  arti- 
ficially emptied  before  the  seventh  month,  the  child  will  be  defi- 
nitely lost  and  the  patient  not  improved.  By  evacuating  an  ap- 
pendiceal abscess  before  emptying  the  uterus  one  avoids  flooding 
the  free  peritoneal  cavity  with  pus.  Operations  for  appendicitis 
are  performed  under  local  or  general  anesthesia.  Some  operators 
resort  to  lumbar  anesthesia.  Operate  as  rapidly  as  is  consistent 
with  thoroughness  and  the  patient's  welfare. 

The  operation  of  election  is  appendectomy,  the  technique  of 
which  is  little  influenced  by  the  presence  of  pregnancy.  The  same 
surgical  principles  are  applicable  in  the  pregnant  as  in  the  non- 
pregnant. 

When  in  doubt  as  to  whether  the  case  is  one  of  appendicitis, 
salpingitis,  tubal  pregnancy  or  other  pathological  conditions,  use 
a  supra-pubic  median  incision.  This  incision  affords  easy  access 
to  most  of  the  pelvic  contents,  and  though  it  is  not  the  incision  of 
election  for  exposure  of  the  appendix,  it  is  a  very  serviceable  in- 
cision. In  cases  of  combined  appendicitis  and  salpingitis,  com- 
bined appendicitis  and  tubal  pregnancy,  combined  uterine  myoma 
and  appendicitis,  etc.,  the  median  infraumbilical  incision  should 
be  employed. 

In  125  of  our  cases  the  appendix  was  removed.  In  forty-three 
cases,  it  is  not  stated  whether  it  was  removed  or  not.  In  five 
cases,  it  was  sought  but  not  found,  and  therefore,  not  removed. 
Each  of  these  cases  presented  an  abscess,  which  was  evacuated 
and  drained.    If  the  appendix  be  imbedded  in  a  mass  of  firm  in- 


ORIGINAL  COMMUNICATIONS  138 

flammatory  adhesions,  it  can  be  removed  by  shelling  it  out  of  its 
peritoneal  coat. 

An  appendical  abscess  should  be  opened  at  its  point  of  maximal 
bulging;  preferably  through  a  cutaneous  surface.  If  the  appen- 
dix be  not  easily  found,  be  content  with  incising  the  abscess,  evac- 
uating its  contents  and  resorting  to  tube  or  gauze  drainage.  A 
subsequent  operation  will  rarely  be  required  to  remove  the  appen- 
dix. Appendiceal  abscesses  have  been  opened  and  drained  through 
the  vagina.  Appendical  abscesses  have  also  been  opened  through 
the  rectum.  These  are  exceptional  procedures :  methods  of  ne- 
cessity not  of  election. 

The  post-operative  treatment  is  that  which  is  employed  in  the 
non-gravid  modified  only  by  a  longer  sojourn  in  bed,  thereby  giv- 
ing time  for  firm  consolidation  of  the  operative  wound. 

POST-OPERATIVE   COMPLICATIONS  AND   SEQUELAE., 

In  cases  of  such  widely  dififerent  nature  as  those  herein  studied, 
operated  in  dififerent  surrounding  and  by  dififerent  operators,  one 
is  not  surprised  to  find  noted  the  occurrence  of  post-operative 
complications  and  post-operative  sequelae.  The  danger  of  hernia 
development  after  timely  operations  for  appendicitis  is  practically 
nil.  The  protection  of  the  operative  scar  by  the  aid  of  adhesive 
plaster  has  been  recommended.  See  that  labor  be  not  unduly  pro- 
longed. 

Among  the  sequelse  reported  in  these  cases  were  four  ventral 
hernias,  three  cases  of  dififuse  peritonitis,  thrombosis  of  femoral 
veins,  phlebitis,  subphrenic  abscess,  intestinal  fistulse,  etc. 

SUMMARY. 

1.  Appendicitis  occurs  at  all  ages  and  in  both  sexes.  It  pre- 
sents to  all  medical  men  important  diagnostic,  prognostic  and 
therapeutic  features. 

2.  Appendicitis,  acute  or  chronic,  initial,  relapsing  or  recur- 
rent, primary  or  secondary,  complicates  pregnancy  with  greater 

It  is  not  necessary  to  split  the  epididymis,  but  only  the  infected 
tion  of  pregnancy. 


134     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

3.  It  occurs  in  single  and  twin  gestations ;  in  first,  early  and  late 
pregnancies ;  in  primiparse,  deutiparae,  and  multiparae. 

4.  It  occurs  at  all  periods  of  the  child-bearing  age  and  at  all 
periods  of  gestation.  It  complicates  both  intra-  and  extra-uterine 
pregnancies  and  can  co-exist  with  other  disease  processes  to  which 
it  may  be  primary,  secondary  or  co-incidental. 

5.  Gestation  exerts  no  untoward  influence  upon  the  normal  ap- 
pendix. It  can  and  frequently  does  aggravate  existing,  or  deter- 
mine new  inflammatory  disturbances  in  appendices  deviating  from 
the  normal  in  form,  length,  mobility,  location,  etc.,  in  appendices 
bound  down  by  adhesions  or  the  seat  of  inflammatory  or  other 
degenerative  changes.  Pregnancy  does  not  relieve  the  dangers 
of  appendicitis,  but  aggrevate  them. 

6.  Appendicitis  and  uni  or  bilateral  tubal  pregnancy  are  fre- 
quently mistaken  for  each  other.  They  may  occur  simultaneously 
or  consecutively,  may  be  either  primary  or  secondary  to,  or  inde- 
pendent of  each  other. 

7.  In  appendicitis,  in  ectopic  pregnancy  and  in  combined  ap- 
pendicitis and  ectopic  pregnancy,  of  obscure  symptomatology,  it 
matters  not  whether  you  are  certain  or  in  doubt  as  to  the  real 
diagnosis,  early  and  timely  operative  treatment  is  imperatively  in- 
dicated. 

8.  During  gestation,  every  type  of  appendicitis  may  occur: 
adhesive,  catarrhal,  gangrenous,  ulcerative,  obliterative,  perfor- 
ative and  suppurative. 

9.  Appendicitis  with  adhesion  formation  is  of  great  signifi- 
cance because  adhesions  of  inflammatory  origin  can  (a)  incar- 
cerate the  pregnant  uterus  in  the  pelvis  and  mechanically  hinder 
the  enlargement  of  the  uterus,  (b)  impair  the  contractibility  of  the 
uterus,  (c)  interfere  with  uterine  labor  contractions,  (d)  entail 
subinvolution,  (e)  induce  sterility,  (f)  disturb  tubal  and  ovarian 
integrity  of  function  and  of  structure,  (g)  determine  ileus,  (h) 
produce  abortion  and,  (i)  lead  to  extra-uterine  pregnancy. 

10.  Chief  among  the  co-existing  pathological  conditions  noted 
in  appendicitis  are  simultaneous  or  consecutive  inflammation  of 
the  uterus,  tubes  or  other  pelvic  organs.     The  close  anatomical 


ORIGINAL  COMMUNICATIONS  136 

relations  existing  between  the  appendix  and  the  pelvic  organs  ex- 
plain their  frequent  association  in  disease  processes. 

11.  Appendicitis  has  a  greater  morbidity  and  a  higher  mortality 
in  the. pregnant  than  in  the  non-pregnant,  operated  or  non-oper- 
ated.   It  may  terminate  pregnancy. 

12.  The  symptomatology  of  appendicitis  in  the  pregnant  is  the 
same  as  in  the  non-pregnant.  The  clinical  picture,  however,  is 
blurred  by  the  co-existing  symptoms  of  pregnancy.  Diagnostic 
mistakes  may  be  lessened  by  keeping  in  mind  that  appendicitis 
occurs  in  pregnant  women;  that  a  history  of  previous  attacks 
during  the  same  or  previous  pregnancies  can  frequently  be  elicited 
by  thorough  and  deliberate  physical  examination.  With  care, 
one  can  in  these  cases  almost  always  arrive  at  a  correct  diagnosis. 

13.  To  establish  with  certainty  the  diagnosis  of  appendicitis 
during  pregnancy,  it  is  necessary  to  exclude  the  presence  of  my- 
algia due  to  stretching  of  abdominal  muscles,  typhoid  fever,  n.ip- 
tured  or  non-ruptured  tubal  pregnancy,  cholecystitis,  salpingitis, 
ovaritis,  adnexitis,  ovarian  cyst  with  or  without  a  twisted  pedicle, 
rightsided  pyelitis  and  ureteritis,  fecal  impaction,  hepatic  and  ne- 
phritic colic.  At  times,  any  of  the  forementioned  conditions  so 
closely  resemble  appendicitis  as  to  cause  diagnostic  errors  and 
operative  mistakes. 

14.  The  morbidity  and  mortality  of  appendicitis  complicating 
pregnancy  and  the  puerperium  are  the  morbidity  and  mortality 
of  delay  in  applying  efficient  surgical  treatment.  The  initial  symp- 
toms of  the  attack  do  not  enable  the  clinician  to  foretell  accurately 
how  a  given  case  will  terminate.  What  is  going  to  happen  in  ten, 
twenty  or  forty  hours  following  the  onset  of  appendicitis  can  not 
be  foreseen.  When  the  condition  is  diagnosed  and  remedied 
early,  the  mortality  is  practically  nil.  Abscess  formation  may 
be  forestalled  by  early  diagnosis  and  early  operation.  The  high 
mortality  is  due  to  late  diagnosis  and  late  operation.  The  preg- 
nant woman  whose  metabolism  is  good  is  a  good  subject  for  op- 
erative measures. 

15.  Prognosis  is  better  for  the  mother  if  there  be  no  interrup- 
tion of  pregnancy  spontaneous  and  otherwise.  The  bad  attacks 
cause  abortions  and  abortion  aggravates  the  illness.    In  the  great 


186     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

majority  of  surgically  treated  cases  there  is  no  interruption  of 
pregnancy  and  when  it  does  occur  it  is  not  due  directly  to  the 
operation.  The  interruption  of  pregnancy  is  not  indicated.  It 
aggravates  the  prognosis.  The  fetal  prognosis  is  good  in  early 
operated  cases. 

16.  The  following  prophylactic  measures  are  sound  and  safe 
and  are  recommended  for  general  adoption:  (a)  During  the  child- 
bearing  age,  recurrent  attacks  of  pelvic  pain,  dysmenorrhea,  men- 
strual and  other  pelvic  disturbances  unassociated  with  objective 
pelvis  findings  are  not  infrequently  due  to  unrecognized  appendi- 
citis or  sequelae  thereof.  In  the  presence  of  this  etiological  fac- 
tor, the  ablation  of  the  appendix  is  indicated,  (b)  In  laparot- 
omies for  conditions  other  than  appendicitis,  the  appendix  should 
be  examined.  Should  it  present  any  deviation  from  the  normal, 
its  removal  is  indicated,  (c)  During  the  child-bearing  age,  any 
woman  who  has  had  one  or  more  attacks  of  appendicitis  treated 
non-operatively  should  have  her  appendix  removed  so*  as  to  cor- 
rect existing  pathological  conditions  and  prevent  future  attacks 
of  appendicitis  and  complications  incident  thereto.  True  prophy- 
laxis in  a  woman  of  child-bearing  age  who  has  had  one  or  more 
well  marked  attacks  of  appendicitis  is  an  interval  operation.  It 
goes  without  saying  that  constipation  is  to  be  avoided  and  that 
other  hygienic  precautions  are  to  be  observed. 

17.  A  definite  and  accurate  diagnosis  of  acute,  chronic  or  re- 
current appendicitis,  irrespective  of  the  stage  of  pregnancy,  in- 
variably calls  for  operation.  The  disease  during  pregnancy  runs 
such  a  rapid  destructive  course  that  delay  is  hazardous.  Opera- 
tion should  be  early  and  immediate.  A  case  may  be  rendered 
hopeless  by  hesitation  and  inaction.  Temporizing  methods  are 
extremely  dangerous. 

18.  Treat  appendicitis  in  the  pregnant  female  as  you  treat  it 
in  the  non-pregnant.  Every  pregnant  woman  who  is  a  subject  of 
appendicitis  should  be  operated  on  just  as  soon  as  the  diagnosis  is 
made,  whether  the  attack  is  the  first,  second  or  third. 

The  unusual  risks  of  leaving  a  diseased  appendix  in  the  ab- 
dominal cavity  are  much  increased  by  the  pregnant  state  and  the 
evil  consequences  of  another  attack,  i.  e.,  gangrene  or  perfora- 


ORIGINAL  COMMUNICATIONS  137 

tion  will  be  correspondingly  greater.  The  danger  of  recurrence 
in  the  later  months  of  pregnancy  and  in  the  child-bed  period  calls 
for  operation  preferably  during  the  attack.  If  the  patient  is  not 
seen  in  time,  one  will  do  the  next  best  thing,  an  interval  operation 
during  the  pregnancy.  Pregnancy  is  an  additional  indication  for 
operation  in  cases  of  appendicitis. 

19.  In  inflammatory  disease  of  the  appendix,  the  ideal  opera- 
tion is  an  appendectomy.  In  some  cases,  however,  one  has  to  be 
content  with  incision,  evacuation  and  drainage  of  an  appendiceal 
abscess.  Exceptionally  drainage  of  abscesses  in  Douglas'  pouch 
may  be  effected  through  the  vagina  or  rectum.  Pus  should  be 
evacuated  irrespective  of-uterine  contents,  and  irrespective  of  its 
location. 

20.  It  is  well  to  keep  in  mind  that  for  an  appendectomy  tlie 
median  incision  is  contraindicated  in  the  later  months  of  preg- 
nancy, that  it  is  best  to  avoid  or  to  reduce  to  a  minimum  the  man- 
ipulations of  the  uterus ;  opiates  are  indicated  in  the  after  treat- 
ment. Labor  when  it  occurs  shortly  after  a  laparotomy  is  not  to 
be  unduly  prolonged :  it  may  have  to  be  assisted. 


188     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERV 


Btltttth  KvtxdtB 


ANEURISMAL  OBSTRUCTION  OF  VENA  CAVA  SUPE- 
RIOR WITH  SPECIAL  REFERENCE  TO  THE 
-     CAVAL  SYNDROME. 


BY  P.  G.  SKILLERN,  JR. 


Skillem  reports  in  the  International  Clinics  an  example  of  this 
condition  and  also  gives  a  brief  review  of  the  literature.  The 
caval  syndrome  is  described  as  follows : 

This  consists  of  enormous  cedematous  swelling  of  the  head, 
neck,  trunk,  upper  extremities,  and  marked  obstruction  of  the 
veins.  These  clinical  manifestations  depend  upon  the  formation 
of  a  collateral  circulation,  the  extent  of  narrowing  of  the  vena, 
and  the  size  and  extent  of  the  pathologic  process  which  causes  the 
compression. 

The  first  result  of  compression  is  obstruction  of  the  venous 
blood  in  the  entire  territory  of  the  vena  cava  superior.  Through 
dilation  of  all  veins  and  capillaries  in  the  territory  of  the  upper 
half  of  the  body  an  enormous  cyanosis  is  often  caused.  The  re- 
sult of  the  obstructed  outflow  of  venous  blood  while  more  blood 
is  continually  being  brought  to  the  part  is  the  appearance  of  oede- 
ma. From  the  distribution  of  the  oedema  and  its  further  advance 
one  may  draw  diagnostic  conclusions  as  to  the  site  of  compres- 
sion. The  lower  half  of  the  body  is  almost  always  free  from 
oedema,  but  the  latter  appears  here  as  well  when,  through  over 
distension  of  the  inferior  vena  cava  obstruction  in  the  tributaries 
of  this  vein  results,  or  when  through  cardiac  weakness  oedema 
appears  in  the  lower  extremities  and  scrotum.  Usually,  however, 
even  in  this  case  the  swelling  of  the  upper  half  of  the  body  re- 
mains in  characteristic  contrast  to  the  very  much  slighter  oedema 
of  the  lower.  Not  only  the  sub-cutaneous  cellular  tissue,  but  also 
the  deeper  parts  are  involved  by  the  oedema,  especially  the  medi- 


SELECTED  ARTICLES  189 

astinum.  Of  importance  also  is  oedematous  infiltration  of  the  mu- 
cous membranes,  for  thus  oedema  of  the  glottis  may  give  ground 
for  suddenly  appearing  death. 

In  the  "diagnosis"  of  compression  of  the  superior  vena  cava  but 
little  difficulty  is  encountered.  The  diagnosis  is  based  upon  the 
direction  of  a  collateral  circulation  and  the  prominence  and  char- 
asteristic  appearance  of  a  dull,  pulsating  area  and  the  Oliver-Car- 
darelli  symptom. 


140     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


ExtrartB  fmm  ifomr  anh  l^ntexgn  Sourttala 


SURGICAL 


Prostatitis  and  Vesiculitis. 


It  is  noted  by  Goeltz  (N.  W.  Med.)  that  in  the  milder  forms 
of  the  focal  infection  group  massage  and  irrigations  will  often 
give  surprising  relief  and,  if  persisted  in  long  enough,  will  give 
relief  in  all  cases.  In  the  severe  forms  with  arthritis  our  task  is 
harder.  In  these  cases  we  find  a  more  or  less  marked  vesiculitis. 
Where  no  actual  occlusion  of  the  ejaculatory  ducts  of  the  vas  in 
cases  of  epididymitis  has  taken  place,  we  get  good  results  from 
stripping  the  vesicles.  The  improvement  is  slow  and  the  treat- 
ment must  be  continued  over  a  long  period.  If  no  results  are  ob- 
tained by  massage,  vaccines,  rest  and  hot  air  treatments,  opera- 
tion for  drainage  or  removal  of  the  vesicles  or  epididymis  offer 
relief. — The  Medical  Brief. 


Surgical  Treatment  of  Acute  Epididymitis. 


McKenna  (Surgery,  Gynecology  and  Obstetrics,  December, 
1916)  concludes  an  article  with  this  title  as  follows : 

Surgical  interference  is  necessary  only  when  the  patient  is  suf- 
fering excruciating  pain.  When  this  puncture  is  carried  out,  it 
is  quite  necessary  to  divide  the  fasciae  so  as  to  free  the  tension 
from  the  testicle  as  well  as  from  the  epididymis.  Patients  are 
less  apt  to  be  impotent  if  the  posterior  wall  is  divided  carefully 
and  the  pus  drained  off  than  if  the  pus  is  left  for  nature  to  absorb. 
A  blind-stab  operation  is  that  of  a  faker  and  should  not  be  con- 
sidered. It  is  not  enough  to  expose  the  epididymis  and  drain  it ; 
all  the  fasciae  should  be  free. 

It  is  not  necessary  to  split  the  epididymitis,  but  only  the  infected 
chamber  which  stands  out  clearly — The  Therapeutic  Gazette. 


EXTRACTS  FROM  JOURNALS  141 

Etiology  of  Tumors. 


The  pioneer  work  of  Smith  on  the  genesis  of  rapidly  growing 
plant  tumors  has  been  duplicated  in  Germany.  Slices  of  carrot 
inoculated  with  the  bacillus  tumefaciens  have  shown  under  the 
same  experimental  conditions  great  differences  in  rapidity  of 
growth  and  malignancy.  Such  differences  depend  on  the  dispo- 
sition of  the  cells  of  the  part  inoculated.  The  morphology  agrees 
with  that  of  animal  and  human  tumors.  The  B.  tumefaciens 
causes  a  growth  which  resembles  sarcoma  or  fibrosarcoma  in  man. 
It  can  not  be  detected  in  the  tumor  tissue  but  appears  in  smears. 
A  tumor  was  generated  in  a  geranium,  and  attained  such  dimen- 
sions that  the  vitality  of  the  plant  should  have  been  compromised, 
but  the  latter  continued  to  grow  as  usual.  A  piece  of  this  tumor 
was  inoculated  successfully  into  a  slice  of  carrot.  It  further  ap- 
pears that  B.  tumefaciens  is  only  one  of  a  series  of  microorgan- 
isms which  can  cause  growths  to  proliferate  in  vegetable  tissues. 
One  bears  a  close  resemblance  to  B.  subtilis.  They  were  recov- 
ered as  impurities  in  the  cultures  of  B.  tumefaciens.  A  diplococ- 
cus,  as  yet  unnamed,  was  seen  at  first  to  possess  but  slight  tumor- 
generating  power  but  as  successive  generations  were  produced 
this  power  increased  until  it  transcended  that  of  B.  tumefaciens. 
The  B.  subtilis  (hay  bacillus)  is  not  of  marked  virulence. 

This  entire  subject  was  discussed  fully  at  a  session  last  Novem- 
ber of  the  Berlin  Medical  Society  (Berliner  klinische  Wochen- 
schrift,  December  25).  The  opinion  obtained  that  bacteria  act 
merely  as  irritants  in  the  production  of  tumors.  Various  mites 
can  cause  the  formation  of  papillary  and  cystic  tumors  in  plants. 
The  evidence  is  at  present  that  molluscum  contagiosum  is  due  to 
the  activity  of  the  Streptococcus  parvus;  while  a  form  of  epithe- 
lioma in  fowls  is  apparently  caused  by  a  mite,  the  Sarcoptes  niu- 
tans. 

Saul,  the  chief  speaker  at  the  meeting,  in  closing  the  discussion, 
summed  up  the  irritants  of  all  types  which  can  cause  rapid  tumor 
growth.  Not  only  can  chemical  irritants  like  aniline  and  arsenic 
cause  cancer,  but  also  photochemical  irritants  like  the  X-rays  and 
radium.     Mites  and  certain  worms,  as  animal  irritants,  probably 


142     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

produce  their  effects  through  the  irritation  of  their  metabolic 
products.     Bacteria  also  act  as  mere  irritants. — Medical  Record. 


Magnesium  Sulphate  in  Tetanus, 


Cammaert  injected  intravenously  50  c.c.  of  a  10  per  cent  solu- 
tion twice  a  day  in  a  case  of  tetanus  in  a  young  man.  The  symp- 
toms of  tetanus  had  developed  about  five  days  after  a  rusty  nail 
had  pierced  one  of  his  toes.  There  were  no  funher  general 
spasms  after  the  first  injection  of  the  magnesium  sulphate,  and 
all  the  symptoms  gradually  subsided  to  complete  recovery  by  the 
end  of  the  second  week.  The  drug  was  so  strikingly  effectual  in 
this  case  that  Cammaert  suggests  that  it  might  prove  useful  in 
eclampsia,  in  uremic  convulsions,  and  for  children  with  convul- 
sions from  whooping  cough  or  other  cause. — The  Journal  of  the 
American  Medical  Association. 


Local  Anesthesia  in  Abdominal  Surgery. 


L.  W.  Grove,  of  Tuscaloosa,  Alabama,  in  the  October,  1916, 
issue  of  the  Southern  Medical  Journal,  writes  on  "Local  Anes- 
thesia in  Abdominal  Surgery." 

Stimulated  by  the  ideas  of  Crile  presented  in  his  discussions 
of  anoci-association  anesthesia,  we  have  been  able,  by  the  use 
of  liberal  amounts  of  i  to  400  novocain  in  connection  with 
morphin  and  scopolamin  in  amounts  sufficient  to  induce  an 
amnesia,  to  produce  a  practically  shockless  anesthesia.  We  have 
successfully  operated  eighteen  cases,  including  acute  and  chronic 
appendicitis,  gastroenrostomy,  cholecystectomy,  ileosigmoidos- 
tomy,  and  two  exploratory  laparotomies.  The  technique  has  been 
easily  carried  out  without  discomfort  to  the  patient  or  the  operator, 
and  in  but  one  case  of  closure  of  upper  abdomen  was  trouble 
experienced.    In  this  a  light  general  anesthesia  was  demanded. 

Notwithstanding  the  majority  of  cases  have  been  among  the 
insane,   they  have  not   shown  elements   of  dementia — upon   the 


EXTRACTS  FROM  JOURNALS  143 

Other  hand,  the  majority  have  been  of  the  exaggerated  or  neu- 
rasthenical  type,  and  we  feel  that  the  technique  would  be  even 
more  applicable  in  the  sane,  who  would  lend  a  more  perfect 
co-operation. 

Our  technique  in  brief  is  as  follows :  Patient  is  given  elimina- 
tive  treatment  in  bed  for  two  days  previous,  but  with  liquid  diet 
continued.  One  hour  before  operation  morphin  14  Gr.,  and  scopo- 
lamin  i-ioo  Gr.,  has  been  given— one-half  hour  later  %  the 
former  dose.  We  have  routinely  made  use  of  one  of  the  right 
rectus  incisions  following  the  infiltration  method  and  perineural 
injection,  and  have  been  able  to  get  free  exposure  without  traction 
on  wound  edges,  mesenfery  or  omentum.  We  have  repeatedly 
shown  that  pain  caused  from  the  handling  of  the  viscera  is  due 
to  traction  and  not  to  trauma,  provided  the  tissues  are  properly 
infiltrated.  The  post-operative  discomfort  is  practically  nil. 
With  the  exception  of  stomach  cases  light  diet  has  been  resumed 
immediately  following  operation.  There  has  been  little  or  no 
nausea,  they  have  needed  no  sedatives,  and  tympanites  has  been 
the  minimum,  with  voluntary  movements  from  the  bowels  in 
several  cases.  We  have  noted  little  or  no  mental  depression 
following. 

Even  with  a  profound  appreciation  of  the  limitations  of  local 
anesthesia  in  abdominal  surgery,  I  am  sure,  with  a  more  accurate 
knowledge  of  the  technique  and  its  indications,  and  a  clearer 
conception  of  the  various  contra-indications  for  general  anesthe- 
sia, that  local  anesthesia  must  demand  more  and  more  the  atten- 
tion of  the  thoughtful  man  in  surgery. — Medical  Review  of 
Reviews. 


MEDICAL 


A  Clinical  Consideil\tion  of  Migraine. 


Migraine  is  considered  by  the  author  as  the  most  frequent 
headache,  occurring  in  700  of  his  15,000  patients  sick  from  all 
causes.     He  believes  that  the  so-called  acidosis  in  children  may 


144     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

be  a  forerunner  of  a  well  established  sick  headache  habit.  The 
interesting  relation  between  migraine  and  epilepsy  deserve  further 
study.  Among  the  author's  15,000  patients,  epilepsy  occurred  in 
7,  and  both  migraine  and  epilepsy  in  70.  Auerbach's  theory, 
which  attributes  migraine  to  an  actual  disproportion  between  skull- 
cavity  and  volume  of  brain,  needs  further  proof.  In  the  Inter- 
national Clinics  for  December,  Dr.  Litchy  shows  thai  the  diag- 
nosis is  easy  when  there  are  headaches  which  are  unilateral,  pe- 
riodical and  hereditary,  but  when  only  one  or  two  of  these  symp- 
toms are  persent,  or  when  there  is  only  a  periodicity  of  some  of 
the  minor  symptoms  or  possibly  of  the  aurae,  the  diagnosis  may 
be  difficult.  Migraine  is  frequently  mistaken  for  pelvic  disease, 
when  some  of  the  aurae  are  present.  The  psychasthenic  and  the 
gastric  symptoms  frequently  lead  to  confusion  in  diagnosis.  While 
the  underlying  causes  of  migraine  are  vague  and  furnish  little 
light  as  to  treatment,  much  can  be  done  to  ameliorate  the  symp- 
toms by  proper  handling  of  the  exciting  causes  that  aggravate  the 
patient's  general  condition  and  precipitate  the  attacks.  Most 
thorough  investigation  and  careful  individualization  are  indicated. 
Systematic  administration  of  the  bromide  salts  and  avoidance  of 
undue  fatigue  are  especially  recommended. — International  Clinics. 


Birth  Rate  of  White  and  Colored  Races. 


The  relation  between  the  birth  rate  and  the  constitution  of  the 
population  in  respect  of  race  and  nativity  is  of  great  interest. 
For  the  six  cities  in  the  registration  area  in  which  the  colored  pop- 
ulation at  the  last  census  either  numbered  more  than  10,000  or 
represented  more  than  10  per  cent  of  the  total,  separate  figures 
are  given  for  the  white  and  colored  races ;  and  in  all  but  one  of 
these  cities — Washington,  D.  C. — the  birth  rates  shown  for  the 
colored  population  were  lower  than  those  for  the  whites.  It  is 
probable  however,  that  the  registration  of  births  is  less  nearly 
complete  among  colored  than  among  white  persons,  and  that 
therefore  the  rates  shown  for  the  former  class  are  too  low.  The 
death  rates  for  the  colored  population  are  higher,  and  in  many 


EXTRACTS  FROM  JOURNALS  145 

cases  much  higher  than  those  for  the  whites. — Journal-Record  of 
Medicine. 


Blood  Pressure  in  the  Aged. 


L.  M.  Bowes  of  Chicago,  in  the  January  Journal  of  Laboratory 
and  Clinical  Medicine,  reports  that  in  making  a  study  of  the  blood 
that  repeated  observations  of  both  sides  of  the  body  were  of  great 
pressure  of  150  cases  between  the  ages  of  65  and  95,  it  was  found 
of  vahie  in  diagnoses,  prognoses  and  treatment. 

On  account  of  the  great  hardness  of  the  blood  vessels  of  some, 
it  was  very  difficult  to  get  true  and  accurate  readings.  A  few  were 
liable  to  have  a  hemorrhage  occur  in  the  anterior  surface  of  the 
wrist  because  of  the  brittleness  of  the  small  blood  vessels.  This 
accident  happened  in  one  case,  but  without  any  bad  effects. 

A  number  of  the  more  feeble  tired  easily,  making  it  necessary 
to  make  all  observations  as  quickly  as  possible,  releasing  the  air 
from  the  armlet  between  each  reading  and  not  maintaining  the 
pressure  too  long  at  any  time. 

The  average  systolic  and  pulse  pressures  increased  to  the  age 
of  85  and  then  decreased.  The  average  diastolic  pressures  re- 
mained in  the  eighties  except  for  the  period  from  85  to  89.  when 
it  was  90  mm.  of  Hg. 

The  blood  pressures  were  higher  in  women,  except  after  the 
age  of  90. 

Seventy-five  per  cent  showed  an  inequality  of  the  blood  pres- 
sure on  the  two  sides  of  the  body.  This  condition  is  frequent  in 
arteriosclerosis. 

There  was  a  persistent  high  blood  pressure  in  only  25  to  30  per 
cent  of  the  cases  of  marked  arteriosclerosis.  When  the  process 
of  fibroses  involved  the  heart  resulting  in  myocarditis,  the  pres- 
sure fell. 

There  were  constant  high  systolic  and  diastolic  pressure  in  all 
cases  of  chronic  nephritis. 

Most  cases  of  cerebral  hemorrhage  had  a  high  or  increased 
blood  pressure.  High  blood  pressure  diagnosticated  cerebral 
hemorrhage  from  cerebral  embohsm. 


146     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

A  high  pulse  pressure  was  common  in  arteriosclerosis  and  aortic 
regurgitation.  This  was  caused,  in  the  latter  conditions,  by  a 
sustained  high  systolic  with  a  low  diastolic  pressure,  while  in  ar- 
teriosclerosis the  systolic  was  increased  in  greater  proportion  than 
the  diastolic  pressure.  A  lowering  blood  pressure  always  indi- 
cated a  failing  heart. 

The  study  of  the  blood  pressure  greatly  aided  the  author  in 
rendering  more  intelligent  care  to  these  elderly  people. — Medical 
Reviezv  of  Revieivs. 


Arteriosclerosis. 


Certainly  a  large  proportion  of  the  vascular  lesions  one  sees, 
especially  those  in  the  aorta,  is  of  infectious  origin,  judging  from 
the  microscopic  appearances.  That  is  to  say,  they  are  typically 
inflammatory  lesions  which  originate  in  the  media  about  the  vasa 
vasorum.  There  is,  howlever,  a  large  number  of  cases  in  which 
these  inflammatory  lesions  are  absent,  but  in  which  there  are 
evidences  of  degenerative  changes  which  are  represented  by  fatty 
plaques  and  streaks  showing  through  the  intima,  and  others  in 
which  the  lesions  are  merely  productive  ones  affecting  the  intima 
itself.  Practically  all  investigators  who  have  endeavored  to  pro- 
duce vascular  lesions,  experimentally,  with  bacteria,  have  suc- 
ceeded in  causing  inflammatory  lesions  associated  with,  in  many 
cases,  degenerative  changes.  Those  who  have  used  adrenalin 
have  produced  only  degenerative  lesions. 

Blailey^  has  experimented  with  a  toxin — that  of  the  diphtheria 
bacillus — which  he  has  used  in  sublethal  doses  over  different 
periods  of  time,  and  studied  the  effects  upon  the  vascular  system 
and  the  kidneys  of  rabbits.  In  order  to  discover  the  relation  of 
high  blood  pressure,  he  has  used  pituitrin  in  combination  with 
the  toxin  in  one  series.  Pituitrin  was  used  because  it  produces 
no  vascular  lesions.  He  has  been  able  to  produce,  with  large 
doses  of  toxin,  a  vascular  degeneration  involving  the  entire  aorta, 
the  carotids  to  the  base  of  the  skull,  the  subclavians  and  iliacs, 
and,  for  a  varying  distance  distally,  the  brachials,  femorals,  and 


EXTRACTS  FROM  JOURNALS  147 

large  abdominal  vessels.  In  combination  with  pituitrin  extensive 
calcification  occurred,  due,  Bailey  believes,  to  the  production  of 
more  extreme  fatty  degeneration.  In  the  kidneys  the  toxin  pro- 
duced a  pronounced  vascular  and  parenchymatous  degeneration. 

Bailey  remarks  that  the  experiments  do  not  shown  the  effects 
of  frequently  repeated  small  doses,  and  it  strikes  one  that  this 
is  what  should  be  shown  if  the  application  is  to  be  valuable.  An 
individual  does  not,  during  disease,  get  a  large  dose  of  toxin  at 
10  a.m.,  and  then  none  for  another  day  or  more.  He  is  poisoned 
by  more  or  less  continuous  absorption  of  toxic  materials  which 
are  produced  in  gradually  increasing  amounts  and  then  in  grad- 
ually decreasing  amounts.  In  diphtheria,  the  course  of  the  disease 
is  short  and  the  period  of  absorption  is  brief;  in  typhoid,  the 
course  is  longer ;  in  intestinal  stasis,  it  may  be  very  protracted — 
but  in  all  it  is  continuous. 

The  thing  that  Bailey's  work  is  useful  to  demonstrate  is  that 
a  certain  type  (degenerative)  of  arteriosclerosis  is  not  microbic 
— not  infectious — in  origin,  but  toxic,  and  that  the  lesions  may 
be  produced  by  concentrated  materials. — The  Journal  of  the 
American  Medical  Association. 


Evidence  Admitted  That  Polydactylism  Is  Usually 
Hereditary. 


In  a  statutory  rape  case  testimony  of  a  physician  that  super- 
numerary fingers  are  usually  hereditary  was  held  admissible. 
Polydactylism  is  usually  considered  by  law  writers  under  the 
general  head  of  malformations,  and  is  regarded  by  well-recog- 
nized authorities  as  being  hereditary  and  frequently  caused  by 
consanguineous  marriages.  Under  the  authority  of  Dr.  Thomson, 
surgeon  in  the  general  prison  of  Scotland,  it  is  stated  in  Wharton 
&  Stille's  "Medical  Jurisprudence,"  volume  i,  section  367,  that 
epilepsy,  dipsomania,  spinal  deformities,  stammering,  imperfect 
organs  of  speech,  clubfeet,  cleft  palates,  harelip,  deafness,  par- 
alysis, and  similar  marks  of  physical  degeneration  accompany 


148     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

the  hereditary  lines  of  abnormal  conditions  of  the  human  family. 
— Peojple  V.  Kingcannon,  Illinois  Supreme  Court,  1 14  N.  E.,  508. 


Charcot's  Joint. 


James  Y.  Welborn,  of  Evansville,  Indiana,  in  the  Lancet-Clinic 
for  September  30,  1916,  writes  on  "Charcot's  Joint."  The  author 
says  that  this  lesion  in  ninety  or  ninety-five  per  cent  of  cases 
occurs  in  tabes ;  the  remaining  five  to  ten  per  cent  appears  in 
syringomyelia.  Elbow  and  knee  are  most  frequently  affected; 
the  joint  is  usually  large,  loose  and  filled  with  fluid,  with  increased 
play  of  the  bones.  There  is  often  considerable  deformity  and 
some  limbs  seem  to  be  extended.  Trophic  changes  due  to  the 
underlying  disease  may  affect  any  of  the  tissues,  resulting  in 
necrosis,  dislocation  of  the  bones,  spontaneous  fractures  and  dis- 
location, etc.     Infection  of  the  joint  may  occur. 

In  making  a  diagnosis,  it  is  necessary  to  exclude  inflammatory 
and  tuberculous  joints.  The  recognition  of  the  symptoms  of  the 
underlying  disease  is  the  most  important  pa^t  of  the  diagnosis. 

Two  interesting  cases  are  reported.  The  first  was  a  man  27 
years  of  age  whose  left  arm  was  enormously  enlarged  from  the 
elbow  to  the  fingers  which  were  stubs,  resulting  from  necrosis 
following  frost  bite  six  years  before.  This  fact  is  of  interest — 
the  thermo  anesthesia  found  on  examination  was  probably  present 
at  the  time  when  the  fingers  were  frozen.  The  wrist  was  loose ; 
the  ends  of  the  bone  partly  softened  and  partly  absorbed ;  spon- 
taneous dislocation  had  occurred  as  was  shown  by  the  fluoroscope. 
The  symptoms  elicited  by  physical  examination  were  quite  char- 
acteristic of  syringomyelia. 

The  second  case  was  one  of  tabes,  with  the  various  tests  of 
the  blood  and  spinal  fluid,  positive  for  syphilis.  A  few  months 
before  coming  under  observation  an  enlargement  appeared  in 
the  lumbar  region  with  impaired  motion.  Then  suddenly  a 
prominence  appeared  at  the  third  and  fourth  vertebra — the  third 
had  slipped  over  the  fourth,  pressing  on  the  cauda  equina,  caus- 
ing paresis  of  the  abductor  muscles.  A  brace  was  fitted  which 
enabled  the  patient  to  be  up  and  walk  about  carefully. 


EXTRACTS  FROM  JOURNALS  149 

This  case  was  ended  by  sudden  death,  thought  to  be  due  to 
embolism. — Medical  Review  of  Reviews. 


OBSTETRICAL. 


A  Study  of  the  Menopause. 


Culbertson  {Surgery,  Gynecology  and  Obstetrics,  December, 
1916)  concludes  his  article  as  follows: 

The  monopause  is  a  functional  derangement  on  the  part  of  va- 
rious glands  of  the  endocrine  system  subsequent  to  the  cessation 
of  the  ovarian  secretion. 

On  this  basis  may  be  explained  the  psychic  and  somatic  mani- 
festations of  the  menopause. 

The  vasomotor  disturbance  represent  an  instability  of  arterial 
tension. 

In  the  majority  of  cases  this  takes  the  form  of  a  vacillating 
hypertension,  both  systolic  and  diastolic. 

The  diastolic  pressure  is  not  elevated  proportionately  to  the 
systolic.     This  produces  an  increased  pulse-pressure. 

Hot  flushes,  sweating,  and  other  vasomotor  symptoms  are  di- 
rectly created  by  the  vacillations  in  arterial  tension. 

In  a  minority  of  cases  there  is  arterial  hypotension,  and  here 
also  the  systolic  and  diastolic  pressures  are  out  of  proportion. 

Hypertension  is  apparently  due  to  a  relative  oversufificiency  on 
the  part  of  the  hypophysis  or  the  adrenal. 

The  psychic  symptoms  are  apparently  influenced  by  thyroid 
dysfunction — in  the  majority  of  cases  a  hyperthyroidism,  in  the 
minority  a  hypothyroidism. 

The  administration  of  the  missing  hormone,  represented  by 
the  extract  of  corpora  lutea  from  animals  in  early  gestation,  brings 
about  a  gradual  restoration  to  normal  of  the  blood-pressure  with 
disappearance  of  the  mental  symptoms. 

This  reduction  of  blood-pressure  by  organotherapy,  together 
with  the  disproportionate  systolic  and  diastolic  rise,  is  offered 
as  evidence  that  the  hypertension  is  a  functional  one  and  not  due 
to  organic  changes. 


150     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Blood-pressure  estimation  is  essential,  as  a  means  both  of  meas- 
uring the  degree  of  menopause  disturbance  and  of  controlling  its 
therapy. 

An  occasional  pressure  reading  is  of  little  or  no  value.  Ten- 
sion must  be  determined  at  frequent  intervals,  preferably  daily 
until  improvement  is  well  under  way. 

The  significance  of  functional  hypertension  as  a  factor  in  uter- 
ine hemorrhage  is  obvious  and  will  be  made  the  subject  of  a  sub- 
sequent report. — The  Therapeutic  Gazette. 


Radiotherapy  of  Uterine  Neoplasms. 


Klein  here  reports  the  present  findings  in  women  treated  at 
the  Munich  clinic.  The  Roentgen  rays  are  combined  with  radium 
and  radio-active  substances  and  a  preparation  of  radium  barium 
selenate  is  injected  intravenously.  The  exposures  are  made  about 
once  a  month  until  there  are  no  more  clinical  evidences  of  the 
cancer.  Over  18.5  per  cent  of  the  ninety-two  patients  with 
inoperable  malignant  disease  of  the  uterine  cervix  have  had  no 
further  sign  of  trouble  during  the  interval  since.  It  ranges  from 
four  months  to  three  years.  About  50  per  cent  of  the  thirty-two 
operative  cases  are  still  free  from  recurrence  after  an  interval 
of  from  twelve  to  eighteen  months,  although  in  half  of  these 
there  had  been  recurrence  from  one  to  three  times  before.  One 
patient  who  had  had  a  mammary  cancer  return  three  times  pre- 
viously, has  been  free  from  recurrence  during  the  five  and  a  half 
years  to  date,  since  the  actinotherapy.  His  numbers  are  small, 
he  admits,  but  the  subsidence  for  several  years  to  date  of  in- 
operable uterine  cancer  and  the  absence  of  further  recurrences 
in  the  previously  recurring  operative  cases  are  features  unknown 
with  exclusively  operative  measures.  Even  those  who  have 
succumbed  to  their  cancer  were  given  a  year  or  more  of  life  and 
freedom  from  clinical  disease.  Smooth  and  complete  healing  was 
the  invariable  rule  with  cancers  of  the  face.  A  complete  cure 
was  realized  also  in  all  cases  of  uterine  fibromas  and  in  nearly  all 
of  myomas. — The  Journal  of  the  American  Medical  Association. 


EDITORIALS  161 


iEbitnrial 


Publish  8»'8  Noticb— The  Joarnal  is  published  In  monthly  nambers  of  48  pares 
at  $100  a  year,  to  be  always  paid  in  advance. 

All  bills  for  advertisements  to  be  paid  quarterly,  after  the  first  insertion  of  the 
quarter. 

Business  communications,  remittances  by  mail,  either  by  money  order,  draft,  or 
registered  letter,  should  be  addressed  to  the  Business  manager,  C.  S.  Brigres,  M.  D. 
corner  Summer  and  Union  Streets,  Nashville,  Tenn. 

All  communications  for  the  Journal,  books  for  review,  exchanees,  etc..  should  be 
addressed  to  the  Editor. 


The  Large  Incision. 


If  there  is  one  stumbling  block  against  which  many  surgeons 
bump  more  than  any  other  it  is  the  short  incision.  The  only  way 
to  account  for  this  is  that  in  preaseptic  days  the  short  incision  was 
considered  the  better,  since  most  wounds  suppurated  and  the 
shorter  the  incision  the  shorter  the  period  of  suppuration.  Tra- 
dition then  is  probably  the  best  explanation  of  this  predominating 
surgical  fault  and  tradition  is  hard  to  overcome. 

The  long  incision  heals  as  rapidly  as  the  short  one,  much  more 
rapidly  if,  in  order  to  get  a  good  operative  field  the  walls  of  the 
short  incision  are  widely  retracted  and  traumatized.  Traumatiza- 
tion  invites  infection  and  infection  delays  restitution.  Aside  from 
the  better  healing  of  a  non-traumatized  wound  there  are  the  many 
advantages  of  a  good  exposure  of  the  field  of  operation.  With  a 
good  exposure  and  everything  accessible,  the  most  difficult  sur- 
gery resolves  itself  into  a  knowledge  of  anatomy  and  pathology 
and  an  ability  to  cut,  tie  and  sew  which,  it  must  be  confessed,  in 
the  average  good  surgeon  compares  very  unfavorably  with  the 
ability  of  a  seamstress  to  do  the  same  things. 

In  visiting  clinics  we  try  to  judge  an  operator  by  his  work  more 
than  by  his  reputation  and  we  have  found  that  the  surgeon  who 
makes  a  free  incision  and  obtains  a  good  exposure  usually  gets  in 
and  gets  out  quicker  and  better  than  some  with  big  reputations 
who  measure  their  skill  in  reverse  ratio  to  the  length  of  their  in- 
cision.— W.  T.  B. 


162     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 
The  American  Medical  Association. 


The  annual  meeting  of  the  American  Medical  Association  will 
be  held  in  New  York  City,  June  4-8,  1917,  and  as  this  is  the  first 
meeting  held  in  that  city  for  many  years  a  record-breaking  at- 
tendance is  predicted.  We  are  in  receipt  of  the  program  of  clin- 
ical sessions  that  has  been  arranged  for  this  meeting  and  regret 
very  much  that  lack  of  space  prevents  the  Journal  from  publish- 
ing. We  can  see,  however,  from  this  full  program  that  the  clin- 
ical arrangements  will  prove  a  feature  of  the  reunion.  Every  phy- 
sician who  can  possibly  arrange  it  should  make  an  effort  to  attend 
this  representative  body  and  take  his  part  in  the  transactions  of 
the  body,  even  if  that  part  be  only  his  presence.  The  upheaval 
of  the  impending  War  and  its  influence  on  medical  men  and  med- 
ical matters  should  make  it  a  duty  of  everyone  to  attend  this  na- 
tional medical  organization. 


Middle  Tennessee  Medical  Association. 


We  acknowledge  the  receipt  of  program  of  the  forty-sixth 
meeting  of  this  flourishing  society,  representing  the  profession  of 
this  central  section  of  the  State,  which  meeting  is  to  be  held  in 
Fayetteville,  Thursday  and  Friday,  May  17  and  18.  This  society 
meets  twice  annually  in  different  cities  of  the  mid-state  and  is 
made  up  of  a  large  membership  of  the  representative  physicians 
of  this  section.  The  papers  announced  for  this  meeting  are  on 
live  subjects  by  live  men  and  much  pleasure  and  profit  is  promised 
to  those  attending.  We  wish  for  the  association  a  successful 
meeting-  this  time  and  a  large  and  useful  existence  for  the  future. 


"Health  Is  Wealth." 


Mr.  Citizen,  have  you  taken  into  consideration  in  making  plans 
for  your  material  welfare  during  the  coming  summer  and  fall, 
that  the  health  of  yourself  and  your  family  may  determine 
whether  or  not  this  is  to  be  a  successful  year  for  you?  If  you 
are  a  merchant,  have  you  stopped  to  reflect  that  a  case  of  typhoid 


I 


EDITORIALS  163 

fever  in  your  family  will  affect  your  assets  in  exactly  the  same 
way  as  the  loss  of  a  valuable  shipment  of  merchandise?  If  you 
are  a  farmer,  has  it  occurred  to  you  that  such  an  illness  may  off- 
set the  value  of  a  bountiful  crop  on  many  acres  of  your  land?  If 
you  are  a  wage  earner,  have  you  considered  that  illness  of  your- 
self or  a  member  of  your  family  will  materially  affect  the  plans 
you  have  made  for  the  investment  of  your  savings  ? 

You  have  thought,  of  course,  of  how  unfortunate  it  would  be 
for  such  illness  to  "happen"  in  your  family.  You  have  insured 
your  merchandise  against  loss.  You  have  insured  your  house  and 
barn  against  fire.  You  have  perhaps  even  taken  out  an  insurance 
policy  to  provide  for  the  "necessities  of  life  for  your  family  in 
case  you  become  ill.  But  have  you  given  to  the  question  of  PRE- 
\'EXTIXG  such  illness  the  thought  and  study  that  so  important 
a  matter  deserves  ?  And  many  of  our  most  serious  and  costly  dis- 
eases are  entirely  preventable. 

The  United  States  Public  Health  Service  devotes  much  of  its 
time  and  effort  to  the  study  of  these  preventable  diseases,  and  has 
issued  numerous  publications  containing  the  fundamental  princi- 
ples of  disease  prevention.  The  titles  of  a  few  of  these  publica- 
tions are  here  given.  Any  or  all  of  them  will  be  sent  to  you  free 
of  charge  on  request : 

"Good  Water  for  Farm  Homes,"  Public  Health  Bui.  No.  70. 

"Typhoid  Fever — Its  Cause  and  Prevention,"  Public  Health 
Health  Bui.  No.  69. 

"Prevention  of  ^Malaria,"  Reprint  No.  170. 

"The  Prevention  of  Pellagra,"  Reprint  No.  307. 

"Tuberculosis — Its  Predisposing  Causes,"  Supplement  No.  3. 

"Hay  Fever  and  Its  Prevention,"  Reprint  No.  349. 

"Infantile  Paralysis,"  Reprint  No.  350. 

"Malaria — Lessons  on  Its  Cause  and  Prevention,"  Supplement 
No.  18.     (For  use  in  schools. ) 

"Fighting  Trim — The  Importance  of  Right  Living,"  Supple- 
ment No.  5. 

"What  the  Farmer  Can  Do  To  Prevent  ^lalaria."  Supplement 
No.  11. 

"The  Care  of  the  Baby,"  Supplement  No.  10. 


164     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 
Do  You  Know  That 


Being  healthy  is  the  first  duty  of  a  citizen  ? 
Disease  is  the  greatest  foe  to  human  progress? 
It's  the  unused  body  that  deteriorates  quickest? 
Fly  destruction  is  its  own  reward? 
A  walk  in  the  open  is  worth  two  in  the  house  ? 
Personal  hygiene  is  the  first  requisite  for  community  health? 
A  small  mosquito  is  a  dangerous  thing  ? 

Most  of  the  diseases  from  which  man  suffers  are  peculiar  to 
man? 


American  Proctological  Association. 
Program. 


Commencing  June  4,  1917.     Executive  Council  meets  at  8  a.m. 

Annual  Address  by  the  President :  "The  Place  of  the  Proctologist 
in  a  Diagnostic  Group" — Alfred  J.  Zobel,  San  Francisco.  Cal. 

Memorial  Address :  "Our  Late  Member,  George  J.  Cook,  Indian- 
apolis, Ind. — Alois  B.  Graham,  Indianapolis,  Ind. 

papers. 

1.  Adult  Rectal  Prolapse;  Two  Cases  and  a  Contrast — Ralph  W. 

Jackson,  Fall  River,  Mass. 

2.  Adenomyoma  of  the  Rectum — Frank  C.  Yoemans,  New  York 

City,  N.  Y. 

3.  Summary  Reports  of  Nine  Cases  of  Peri-Colic  Membrane — 

John  L.  Jelks,  Memphis,  Tenn. 

4.  Should  the  Sphincters  be  Divided? — Rollin  H.  Barnes,   St. 

Louis,  Mo. 

5.  Neglected  Rectal  Examination — James  A.  McVeight,  Detroit, 

Mich. 

6.  Enemas  and  Colonic  Flushing  as  Etiologic  Factors  in  Appen- 

dicitis—William M.  Staufifer,  St.  Louis,  Mo. 

7.  The  Relationship  of  Hemorrhoidal  Disease  to  the  Health  Bal- 

ance— William  M.  Beach,  Pittsburg,  Pa. 

8.  The  Underlying  Factors  of  the  Clamp  and  Cautery  Operation 

for  Internal  Piles — W.  Oakley  Hermance,  Philadelphia,  Pa. 


I 


EDITORIALS  1B6 

9.  The  Pathology  of  Hemorrhoids — J.   Coles  Brick,   Philadel- 
phia, Pa. 

10.  Report  of  a  Case  of  Idiosyncracy  to  Quinine  and  Urea  Hy- 

drochloride— Collier  F.  Martin,  Philadelphia,  Pa. 

11.  Neoproctolog-y — A    Glimpse    Into    the    Future — Jerome    M. 

Lynch,  New  York  City,  N.  Y. 

12.  The   Post-Operative   Factor   in   Rectal   Surgery — Barney   J. 

Dry  fuss,  New  York  City,  N|  Y. 

13.  The    Non-Surgical     Treatment    of     Splanchnoptosis — Rolla 

Camden,  Parkersburg,  W.  Va. 


Rectal  Clinics  will  be  held  by  Drs.  Samuel  G.  Gant  and  Jerome 
M.  Lynch.    The  hour  and  place  will  be  announced  later. 


American  Remedies  for  Chinese  Ailments. 


China  will  soon  be  the  greatest  market  in  the  world  for  pro- 
prietary medicines,  according  to  a  bulletin  issued  today  by  the 
Bureau  of  Foreign  and  Domestic  Commerce,  of  the  Department 
of  Commerce,  to  call  the  attention  of  American  manufacturers  to 
the  advantages  of  getting  a  good  foothold  in  the  market  at  once. 

"Hygiene  is  practically  unknown  among  the  Chinese,"  the  re- 
port states,  "and  the  sickness  and  suffering  to  which  the  masses 
are  subject  on  account  of  the  lack  of  efficient  native  remedies  or 
treatment  is  probably  greater  than  in  any  other  country.  This  is 
especially  true  of  all  varieties  of  skin  diseases,  against  which  no 
native  salves  or  blood  tonics  seem  effective." 

Ten  years  ago  the  proprietary-medicine  trade  in  China  was 
hardly  worth  mentioning,  although  foreigners  had  been  laboring 
for  twenty  years  or  more  to  develop  it,  but  immense  strides  have 
been  made  since  then  and  ample  profits  have  been  realized.  The 
trade,  however,  is  still  in  its  infancy. 

Through  judicious  and  persistent  advertising  the  natives  are 
gradually  being  educated  to  the  necessity  of  paying  some  intelli- 
gent attention  to  their  ailments  and  are  responding  remarkably 
well.    For  this  reason  it  is  not  difficult  to  introduce  a  good  article 


166     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

at  a  reasonable  price,  if  supported  by  the  right  kind  of  advertising. 
The  Bureau's  report  is  devoted  chiefly  to  sales  methods  and  ad- 
vertising and  the  material  presented  on  these  subjects  is  new  and 
important.  Copies  of  the  bulletin,  which  is  entitled  "Proprietary 
Medicine  and  Ointment  Trade  in  China,"  Special  Consular  Re- 
ports No.  76,  may  be  purchased  for  5  cents  from  the  Superintend- 
ent of  Documents,  Washington,  or  from  and  district  office  of  the 
Bureau  of  Foreign  and  Domestic  Commerce.  It  contains  12  pages. 


A  Word  To  Our  Advertisers. 


We  are  pleased  always  to  give  space  to  our  advertisers  in  the 
shape  of  reading  notices  in  every  issue,  but  in  view  of  the  fact 
that  the  size  of  our  monthly  issues  has  been  reduced  considerably 
must  request  that  these  reading  notices  be  abridged  as  much  as 
possible  so  as  to  not  encroach  on  the  reading  matter  proper  of 
the  Journal. 


REVIEWS  AND  BOOK  NOTICES  167 


SrlnrhiB  anil  look  Notirffi 


Cancer— Its  Cause  and  Treatment,  by  L.  Duncan  Bulkley,  A.M..  M.D., 
Senior  Physician  to  the  New  York  Skin  and  Cancer  Hospital,  etc.  New 
York.    Paul  B.  Hoeber.     1917. 

We  acknowledge  with  thanks  to  the  obliging  publisher  the  re- 
ceipt of  a  copy  of  this  valuable  book.  The  author  is  well  known  for 
his  numerous  contributions  to  the  science  of  medicine  and  our 
readers  will  realize  that  anything  that  emanates  from  him  will  be 
up-to-date  and  helpful  t©  everyone  interested  in  the  vital  subject 
treated  of  by  the  author  in  this  book.  The  fact  that  the  dread  dis- 
ease is  on  the  increase  in  this  country  and  in  the  world  should  ren- 
der a  study  like  this  of  eminent  importance  to  the  profession.  The 
book  is  made  up  of  six  lectures  delivered  at  the  New  York  Skin 
and  Cancer  Hospital  in  November  and  December,  1916,  as  follows  : 
Lecture  I,  Cancer  as  a  Medical  or  Surgical  Disease;  Lecture  II, 
Influence  of  Sex,  Age,  Occupation,  Race,  Climate,  and  Food  on 
Cancer;  Lecture  III,  The  Mortality  from  Cancer;  Analysis  of 
Surgical  Statistics ;  Lecture  IV,  Inoperable  and  Incurable  Cancer ; 
Metastases ;  The  Blood  in  Cancer ;  Lecture  V,  Dietetic  and  Medi- 
cal Treatment  of  Cancer  Prophylaxis  ;  Lecture  VI,  Results  :  Per- 
sonal Cases— Summary.  The  Real  Cancer  Problem— Index— The 
scope  of  this  excellent  and  painstaking  work  can  be  seen  by  this 
table  of  contents  and  our  readers  would  do  well  to  secure  copies 
of  the  work. 


168     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


PubltBlirr'H  i^partm^nt 


Notifiable  Diseases. 


The  growing  tendency  of  manufacturing  chemists  in  presenting  to  the 
profession  books  and  brochures  containing  valuable  data,  outside  of  the 
references  made  to  their  particular  proprietary  remedy,  encourages  the 
preservation  of  this  literature  on  account  of  the  real  educational  value  of 
th  contents. 

Under  the  above  title,  comes  to  us  a  brochure  of  many  pages,  issued  by 
The  Purdue  Frederick  Company,  of  135  Christopher  Street,  Newr  York, 
manufacturers  of  the  well  known  Gray's  Glycerine  Tonic  Comp.  Formula 
Dr.  John  P.  Gray.)  This  booklet  gives  not  only  those  diseases  that  should 
be  reported  to  the  Board  of  Health,  but  with  each  disease,  a  cHnical  de- 
scription, the  cause,  how  transmitted,  incubation  period,  characteristic 
symptoms,  prognosis,  durational  quarantine,  school  regulations,  and  disin- 
fection. 

It  is  really  a  time  and  labor  saver,  and  if  you  have  not  received  a  copy 
we  are  sure  that  a  card  addressed  to  the  above  mentioned  firm  will  place 
one  in  your  hands. 


When  the  Iodides  Are  Indicated. 


In  latent  syphilis  and  those  many  other  chronic  conditions  indicating  the 
exhibition  of  iodine,  it  will  be  found  that  the  administration  of  lODA 
(Battle)  meets  the  therapeutic  needs,  and  makes  possible  the  introduction 
of  iodine  into  the  system  without  throwing  too  big  a  burden  upon  the  diges- 
tive tract.  In  preparing  lODIA  (Battle)  the  idea  in  mind  has  been  to  se- 
cure a  high  degree  of  iodine  influence  without  deranging  the  gastrointestinal 
function.  For  this  reason  lODIA  (Battle)  is  of  such  usefulness  in  cases 
requiring  the  long  continued  administration  of  iodine. 


Hastening  Recovery  from  Grip  and  Pneumonia. 


It  is  during  convalescence  from  grippal  conditions  and  pneumonia  that 
the  need  for  an  agent  to  augment  tissue  resistance  becomes  a  most  im- 
portant consideration.  For  more  than  twenty  years  Cord.  Ext.  01.  Mor- 
rhuae  Comp.  (Hagee)  has  shown  its  special  value  as  a  reconstructive  dur- 
ing the  recovery  from  bronchial  and  pulmonary  conditions,  a  value  that 
rests  largely  upon  the  case  with  which  the  depleted  system  assimilates  the 
essential  elements  of  cod  liver  oil  which  Cord.  Ext.  Ol.  Morrhuse  Comp. 
(Hagee)  contains.    For  the  purpose  mentioned  this  preparation  is  standard. 


PUBLISHERS'  DEPARTMENT  169 

Post-Operative  Quiet  and  Ease. 


It  frequently  happens  during  convalescense  from  a  surgical  attack  that 
the  patient  is  restless  and  does  not  secure  his  customary  sleep.  The  sur- 
geon hesitates  to  use  narcotic  and  depressing  agents  owing  to  their  ill  after 
effects.  PASADYNE  (Daniel)  lacks  these  evil  qualities  and  hence  is 
adapted  in  high  degree  for  use  in  post-operative  convalescence.  Many  sur- 
geons now  employ  it  routinely,  having  determined  its  therapeutic  potency 
and,  at  the  same  time,  its  incocuousness.  PASADYNE  (Daniel)  is  nothmg 
but  a  concentrated  tincture  of  passiflora  incarnata.  A  sample  bottle  may 
be  had  by  addressing  the  laboratory  of  John  B.  Daniel,  Inc.,  Atlanta,  Ga. 


Chronic  Constipation  of  Women. 


In  the  treatment  of  this  condition,  what  the  physician  may  expect  IN- 
TEROL  to  do  is  the  following : 

(1)  It  keeps  the  feces  from  becoming  dried  and  hard.  That  is,  it  keeps 
them  soft  and  plastic;  (2)  and  in  addition,  by  lubricating  them,  it  (3)  en- 
ables them  to  squeeze  or  slip  through  angulations,  convulsions  and  constric- 
tions of  a  crowded  gut  (4)  at  the  same  time,  there  is  a  protective  action  to 
any  raw  or  abraded  spots. 

3y  doing  these  things  INTEROL  relieves  fecal  pressure  and  gaseous 
dintension,  so  that  the  autotoxic  as  well  as  nervous  symptoms  are  likely 
to  be  reached. 

All  these  it  does  effectively  and  harmlessly.  Its  use  does  not  prevent  the 
adjunctory  use  of  any  orthopoedic,  surgical  or  other  procedure  that  may  be 
indicated.  On  the  contrary,  INTEROL  itself  is  more  an  adjunct  to  such 
other  measures.  ^ 

INTEROL  is  unquestionably  all  that  it  is  claimed  to  be— a  valuable  die- 
tetic accessory."  There  is  no  other  accessory  measure  that  will  better  ac- 
complish what  INTEROL  does  accomplish  in  cases  where  it  can  accom- 
plish it. 

DOSAGE  is  usually  a  tablespoonful  morning  and  night  on  an  empty 
stomach,  although  this  caries  with  the  individual  peculiarities.* 


In  PREGNANCY  where  elimination  is  deficient,  as  indicated  by  head- 
ache, slight  disturbance  of  the  digestion  and  diminution  of  solids  and  urea 
in  the  urine,  sanmetto  in  connection  with  calomel  is  remarkably  effective. 
The  calomel  acts  upon  the  cells  of  the  body,  those  of  the  liver  especially, 
effecting  proper  removal  of  the  waste  and  accumulated  toxins.  Sanmetto 
increased  the  activity  of  the  kidneys,  in  this  way  promoting  the  removal 
of  excrementitious  products  from  the  blood,  and  at  the  same  time  acts  as 
a  systematic  tonic  enabling  the  body  to  more  completely  dispose  of  its 
waste  products  through  its  organs  of  elimination  and  resist  the  evileffects 
from  systemic  absorption  of  auto-toxins. 

"I  have  used  Tongaline  for  more  than  twenty  years  and  have  found  it 
most  satisfactory  in  every  way.    A  very  recent  case  which  came  under  my 

♦Booklet  and  samples  to  physicians.  Van  Horn  and  Sawtell,  15-17  E. 
400  St.,  New  York. 


160     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

care  was  one  in  which  several  physicians  had  failed,  even  with  the  use  of 
organo-therapy.  Within  forty-eight  hours  after  Tongaline  had  been  ad- 
ministered there  was  a  decided  remission  of  temperature  and  pain  and  at 
the  end  of  one  month  the  patient,  who  was  a  lady  about  seventy  years  of 
age,  and  had  been  a  suffered  for  years,  was  able  to  go  about  her  room 
and  to  comb  her  own  hair,  something  which  she  had  not  done  for  six 
months  previously." 

"I  prescribed  Tongaline  for  two  cases  of  tonsillitis,  after  all  other  treat- 
ment had  failed,  with  such  success  that  both  made  a  rapid  recovery." 


i 


NASHVILLE  JOURNAL 

OF  

MEDICINE  AND    SURGERY 


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


Vol..  CXI.  JUNE,  1917.  No.  6 


Original  OInmmumraltnnH 

ALCOHOL  XOT  ALWAYS  THE  PRIMARY  CAUSE 
OF  INEBRIETY. 


BY   T.    D.    CROTHERS,    M.D._,    HARTFORD,    CONN. 


Until  within  a  comparatively  recent  time,  alcohol  has  been  con- 
sidered a  stimulant  and  tonic.  This  theory,  coming  down  from 
the  past,  has  been  unquestioned.  Laboratory  teachings,  confirmed 
by  exact  clinical  research,  show  that  this  theory  is  fallacious ;  that 
alcohol  is  not  a  stimulant  or  tonic,  but  an  anesthetic  and  depres- 
sant, and  that  the  real  causes  of  the  fascination,  comes  from  its 
power  to  cover  up  fatigue,  pain  and  bad  feelings.  Instead  of 
giving  strength  and  new  vigor  to  the  body,  it  simply  conceals  the 
conditions,  previously  existing.  This  is  confirmed  by  careful 
observation  by  the  profession,  and  has  brought  about  a  revolu- 
tion of  theory  and  practice  that  the  younger  men  adopt  quickly 
and  the  older  men  regard  with  some  doubt  yet. 

It  is  a  curious  fact  that  in  Roman  civilization,  insanity  was 
considered  an  obsession  of  the  devil,  and  inebriety  and  drunken- 
ness, simply  as  a  sickness,  dependent  on  physical  conditions.  Up 
until  the  last  century  inebriety  and  alcoholism  were  considered 
moral  disorders  and  insanity  was  considered  a  disease. 


162     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

The  moral  theory  of  the  causes  of  drinking,  has  come  down 
even  to  the  present  time,  although  not  often  mentioned,  except 
among  laymen.  There  are  men  in  the  profession  today  who  talk 
very  decidedly  about  the  vice  element.  The  late  Dr.  Gray  of 
Utica  was  very  emphatic  in  his  opinion  that  all  drunkards  were 
vicious  and  suffering  from  a  moral  disorder.  The  profession, 
generally,  have  recognized  a  range  of  physical  causes,  of  which 
alcohol  is  supposed  to  be  the  principal  and  only  one,  as  responsi- 
ble for  the  evils  which  follow  from  its  use. 

The  curative  efforts  by  reformers  and  laymen  generally,  and 
to  a  large  extent,  those  of  the  profession,  have  been  based  on  the 
assumption  that  alcohol  was  the  principal  and  special  cause,  and 
its  removal  would  be  followed  by  complete  restoration. 

When  individual  histories  of  alcoholics  and  inebriates  are 
studied  carefully,  and  the  physiological  and  psychological  causes 
which  dominate  life  are  determined,  a  new  range  of  forces  ap- 
pear. What  was  supposed  to  be  the  principal  cause,  is  often  only 
a  symptom  of  other  conditions  unknown.  When  these  conditions 
are  removed,  the  desire  for  alcohol  disappears.  The  clinical  evi- 
dence supporting  this  fact  is  very  extensive. 

A  few  examples  will  illustrate  this : 

A  most  exemplary  clergyman,  a  total  abstainer,  after  a  blow 
on  the  head  from  a  fall,  became  a  most  inveterate  inebriate, 
drinking  continually  and  to  great  excess.  After  two  or  three 
years  of  the  most  wretched  existence  he  died  and  a  post  mortem 
showed  a  fractured  skull  and  a  bone  pressure  on  the  brain. 

An  old  soldier  with  a  running  sore  from  a  necrosis  of  the 
fibula,  was,  for  a  few  years,  a  most  incorrigible  drunkard,  until 
finally  the  dead  bone  was  removed,  and  the  wound  was  healed, 
and  he  stopped  all  use  of  alcohol,  and  lived  many  years  a  total 
abstainer. 

A  prominent  banker  drank  at  intervals  and  could  not  abstain 
only  for  a  brief  time,  notwithstanding  his  various  efforts.  He 
finally  gave  up,  and  went  to  Colorado  and  lived  out  of  doors,  and 
made  a  complete  recovery.  Here  unknown  causes  were  at  work, 
not  climatic  or  any  one  thing,  but  something  had  taken  place,  and 
the  drink  craze  died  out. 


•    ORIGINAL  COMMUNICATIONS  163 

Another  prominent  club  man  who  drank  to  intoxication,  nearly 
every  night,  changed  his  business  and  moved  to  a  neighboring 
city,  and  stopped  all  use  of  alcohol.  Every  effort  before  this  had 
failed  and  this  last  effort  he  ascribed  to  some  insignificant  cause, 
but  it  was  evident  that  other  causes  existed,  unknown  to  himself, 
and  the  removal  of  these  was  followed  by  the  subsidence  of  the 
drink  craze. 

The  most  diverse  explanations  and  theories  of  why  men  drink 
and  what  means  are  used  to  stop  them,  have  developed  a  litera- 
ture that  is  confusing  and  unverifiable.  This  shows  that  the  real 
causes  were  unstudied  and  unknown  and  the  results  did  not  come 
from  the  curative  measures  claimed. 

Out  of  the  thousands  of  persons  who  sought  help  from  the 
earliest  empiric  institutions,  a  certain  number  permanently  re- 
covered and  believed  that  the  drugs  and  other  mysterious  methods 
used  were  the  direct  causes  of  cures.  However  varied  the  treat- 
ments might  be,  as  a  rule,  temporary  restoration  followed  in  a 
very  large  portion  of  cases.  A  certain  number  were  unduly  elated 
and  credulous  to  the  last  degree,  in  believing  that  the  real  causes 
of  the  drink  evil  had  been  driven  away,  and  that  they  could  not 
take  it  any  more.  After  a  time  the  impression  that  they  were 
immune  weakened,  and  they  experimented  with  themselves,  to 
show  whether  it  was  true  or  not,  and  relapse  followed.  In  per- 
sons in  whom  the  psychical  causes  were  prominent,  the  influence 
of  mysterious  drugs,  and  the  personal  and  dogmatic  suggestions 
of  the  physician  that  they  would  never  drink  again,  permanently 
impressed  their  mental  condition.  In  others  this  impression  faded, 
and  relapse  followed. 

In  all  these  empiric  efforts,  there  was  only  one  thought,  that 
alcohol  was  the  only  and  specific  cause,  and  the  removal  of  this 
and  aversion  for  it  would  prevent  its  use  again.  The  claims 
that  95  per  cent  were  cured,  were  undoubtedly  justified  by  the 
experience  of  the  first  few  months,  but  when  the  time  was  ex- 
tended to  the  same  number  of  years,  the  percentage  of  failures 
equaled  the  former  claims  of  cure. 

There  was  something  very  suggestive  in  this  wave  of  empir- 
icism, which    sought  to    find  means    of    cure    and  prevention, 


164     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

based  on  the  one  fact  that  the  removal  and  disgust  for  alcohol 
were  the  ends  to  seek  for.  These  various  means  and  methods 
attracted  a  vast  army  of  incurables,  and  aroused  a  most  extrava- 
gant public  sentiment  of  the  possibilities  of  relief.  Literally 
they  educated  public  sentiment  and  in  that  way  they  were  of 
inestimable  benefit  indicating  physical  means  and  measures,  due 
to  alcohol  alone  that  was  doubted  before.  In  another  way,  they 
taught  the  public  and  the  army  of  incurables  that  temporary  and 
possibly  permanent  relief  could  be  secured  by  using  physical 
means  and  measures. 

The  evidence  of  this  change  is  seen  in  every  insane  asylum, 
hospital  and  almshouse,  and  sanitariums  for  inebriates  and  alco- 
holics, in  the  increasing  number  that  come  for  treatment.  Most 
of  these  men  are  satisfied  with  temporary  relief  and  go  away  after 
a  few  days  or  weeks  restored,  indicating  beyond  question  an  in- 
creasing hope  in  the  possibilities  of  permanent  restoration  and 
cure  through  physical  means. 

The  term  rounder  is  used  to  describe  a  class  of  people  who  ap- 
pear in  the  police  court  for  petty  assaults  and  crimes.  The  same 
term  is  used  now  to  designate  a  class  who  appear  in  hospitals, 
both  public  and  private,  many  times  every  year,  for  relief  from 
their  alcoholic  addiction.  After  a  time,  they  relapse  so  frequently 
that  they  have  to  be  committed  for  a  longer  period  of  time. 

In  all  these  institutions,  the  central  fact  is,  that  alcohol  and  its 
removal  constitutes  the  complete  cure.  The  restraint  of  the  in- 
stitution helps  in  some  way,  and  in  others  chemical  restraint  is 
regarded  of  equal  value.  In  some  institutions  chemical  restraint 
is  the  most  prominent  remedial  measure.  It  is  assumed  that  if 
the  desire  for  alcohol  can  be  held  in  abeyance  by  narcotics,  it  will 
disappear  after  a  time.  The  other  symptoms,  such  as  the  relief 
from  toxemias,  congestion  and  local  conditions  of  the  various  or- 
gans, are  regarded  as  secondary.  In  other  places  psychical  sug- 
gestions and  appeals  to  the  fears  and  pride  are  regarded  as  es- 
sential. The  patient  is  made  to  believe  certain  distinct  facts  con- 
cerning the  perils  from  the  use  of  alcohol. 

In  a  number  of  instances,  these  varied  means,  while  apparently 
convincing  the  patient,  fail  to  break  up  the  delusion  and  hope  of 


ORIGINAL  COMMUNICATIONS  166 

the  possibility  of  being  a  moderate  drinker,  and  this  results  in  the 
attempt  in  the  future,  to  repeat  the  same  experiment  again,  hop- 
ing that  by  some  possible  change  he  might  be  able  to  use  beer  or 
wine  in  small  quantities  for  the  remainder  of  life. 

In  all  the  various  drug  combinations,  which  physicians  are  us- 
ing, the  one  central  thought  is,  to  break  up  the  alcoholic  obsession, 
and  there  is  no  thought  of  anything  farther  than  that,  other  than 
an  entailment  from  disabilities,  directly  due  to  spirits.  Every 
now  and  then  an  acute  observer  is  conscious  of  other  causes  than 
alcohol,  and  when  he  directs  his  efforts  to  the  removal  of  these, 
he  is  astonished  at  the  rapidity  in  which  the  alcoholic  impulse 
dies  out. 

The  efforts  of  laymen  show  how  ill  advised  and  how  thoroughly 
materialistic,  and  often  unreasonable  are  the  theories  on  which 
their  relief  work  is  based.  The  literature  is  an  astonishing  com- 
bination of  statements  and  opinions,  with  little  or  no  reference  to 
any  other  cause  than  alcohol. 

The  periodic  drinker  furnishes  the  most  suggestive  illustration 
of  causes  farther  back  provoking  the  paroxysm.  After  a  period 
of  total  abstinence,  and  in  apparently  most  favorable  circumstan- 
ces, he  will  suddenly  develop  a  paroxysm  for  drink  that  is  a  veri- 
table insanity.  This  dies  away  followed  by  an  acute  remorse  and 
consciousness  of  the  loss  he  has  suffered  only  to  be  followed  by 
another  paroxysm.  Alcohol  can  not  be  the  cause  here,  but  is 
only  a  symptom,  and  yet,  little  or  no  observation  has  been  made 
to  determine  the  causes. 

Quite  a  large  proportion  of  these  persons,  whose  drink  im- 
pulse is  more  or  less  secret,  become  very  warm  supporters  of 
certain  drug  combinations  and  certain  institutions,  and  certain 
means  and  measures  of  cure,  claiming  that  they  have  been  per- 
manently restored  by  these  means.  Often  it  is  the  pledge,  the 
prayer,  the  conversion,  the  secret  remedy,  the  personal  influence 
of  some  physician,  clergyman  or  relative,  and  for  a  time  they 
pose  as  examples  and  even  take  a  part  in  helping  others,  who  fail 
to  receive  the  same  benefits.  Then  suddenly  they  fall  back  again, 
and  drink  as  before. 


166      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

There  is  great  confusion  in  the  writings  of  physicians  and 
statements  of  patients,  and  all  because  such  persons  are  never 
studied  physiologically  or  psychologically.  The  real  causes  which 
provoke  the  drink  craze  are  unknown.  As  a  result,  the  methods 
of  relief  fail.  Such  persons  are  enigmas  to  reformers  and  laymen 
and  largely  to  thoughtless  physicians  who  accept  the  common 
theories  that  alcohol  is  the  sole  and  chief  cause. 

The  psychopathic  hospitals  are  based  on  the  fact  that  the  causes 
of  disease,  particularly  of  the  mind,  are  traceable  from  exhaus- 
tive studies  of  the  varied  conditions  of  living  and  thinking,  and 
a  species  of  re-education  pointing  out  to  the  patient  how  to  live 
in  the  most  hygienic  way  to  preserve  and  develop  his  energies. 

There  is  a  vast  army  of  so-called  moderate  drinkers  who  are 
generally  very  active  brain  workers,  and  who  use  spirits  in  small 
quantities  daily  or  at  intervals  and  are  more  or  less  conscious  of 
the  possible  danger  in  this  direction,  a  danger  that  comes  from 
experience  and  observation.  While  they  excuse  themselves  and 
give  reasons  for  the  continuous  use  of  spirits,  and  feel  confident 
that  they  can  stop  at  any  moment,  there  is  an  increasing  desire 
for  help  from  some  source;  a  longing  to  find  some  means  for 
relief.  Often  these  persons  resort  to  quack  drugs  in  secret,  take 
long  journeys,  put  themselves  in  positions  where  spirits  are  diffi- 
cult to  be  procured,  hoping  in  this  way  that  they  can  overcome 
a  so-called  habit,  which  might  become  serious.  They  very  seldom 
appeal  to  physicians  for  help  and  so  drift  down  through  the  years, 
until  some  disease  appears  or  some  great  revolution  takes  place 
in  their  life.  Then  the  long  wished  strength  to  abstain  is  mani- 
fested. 

In  all  these  cases,  there  has  been  no  thought  of  any  other  cause, 
but  alcohol.  Both  the  periodic  and  moderate  drinker  have  never 
been  studied  scientifically.  No  one  questions  why  alcohol  is  fas- 
cinating and  why  it  comes  to  be  regarded  as  essential  to  the  health 
and  vigor  of  the  brain  worker,  as  well  as  the  poor  laborer,  and 
why  it  is  called  for  by  the  pauper  and  the  millionaire  with  the 
same  persistency  and  urgency  as  food. 

A  Research  Foundation  has  been  established  at  Hartford,  Con- 
necticut, for  the  purpose  of  taking  up  this  subject.     It  proposes 


ORIGINAL  COMMUNICATIONS  167 

to  study  the  histories  of  persons  minutely  and  find  out  what 
causes,  other  than  alcohol,  are  prominent  in  the  desire  for  its  use. 
The  question  of  why  men  drink  is  a  scientific  one  and  can  not  be 
studied  from  a  moral  or  sociological  point  of  view.  It  is  one  of 
facts  and  their  meanings,  and  a  Foundation  with  expert  exami- 
ners and  appliances  to  make  exhaustive  examinations  of  the 
victims  and  studies  into  this  new  field  of  causes,  is  along  the  line 
of  the  highest  scientific  work  of  the  present. 

The  alcoholic  evil  with  all  its  diseases  and  associations,  can 
never  be  understood,  until  such  exact  studies  are  made,  until  some 
exact  knowledge  is  ascertained  from  the  histories  of  large  num- 
bers of  persons,  showing  what  physical  and  psychical  causes,  pre- 
dispose and  lead  up  to  the  use  of  alcohol. 

This  Research  Foundation  will  be  endowed  and  become  a  per- 
manent work  and  really  become  a  clearing  house,  where  persons 
can  be  examined  to  determine  what  measures  of  treatment  and 
prevention  are  most  practical. 

There  are  almost  innumerable  persons  who  use  spirits  in  mod- 
eration or  occasionally  to  excess  who,  from  observation  and  ex- 
perience, are  vaguely  conscious  of  danger  from  this  source.  They 
would  like  to  stop,  but  have  no  means  of  knowing  how  and  where 
they  can  receive  benefit  through  counsel  and  advice. 

Such  persons  do  not  want  drugs  or  sanatorium  treatment  and 
have  very  confusing  notions  of  the  possible  relief  from  other 
sources.  They  will  heartily  welcome  any  effort  that  will  enable 
them  to  understand  their  own  condition  and  to  determine  what 
are  the  best  means  for  possible  relief  in  the  future. 

This  Foundation  will  give  much  prominence  to  hereditary  con- 
ditions. Already  studies  have  been  made  in  this  department  which 
indicate  a  great  variety  of  new  facts  not  yet  understood  by  the 
profession.  Psychical  studies  will  also  be  very  prominent,  and  an 
effort  will  be  made  to  know  what  influences  of  this  class  have 
fashioned  and  shaped  the  future  of  the  individual,  giving  a  sus- 
ceptibility to  the  narcotism  of  alcohol,  or  a  peculiar  immunity; 
also  what  physical  changes  have  predisposed  and  favored  the 
demand  for  relief  from  alcohol. 


168     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

At  present  these  conditions  are  unknown  to  a  large  extent,  and 
are  so  mixed  up  with  theories  and  dogmatic  opinions,  that  only  a 
Research  Foundation  can  make  clear.  The  present  treatment  of 
inebriates  and  alcoholics  is  in  a  most  confusing  state,  simply  be- 
cause the  facts  on  which  the  various  efforts  are  based  are  unreal 
and  often  unverifiable.  This  Foundation  will  clear  up  this  con- 
fusion, and  not  only  group  the  present  facts,  but  add  to  them 
immensely  and  lift  the  whole  subject  out  of  the  realm  of  guess 
work  and  empiricism  and  make  it  possible  for  physicians  to  treat 
such  persons  with  as  much  certainty  as  those  suffering  from  any 
other  disease. 


SELECTED  ARTICLES  169 


^Fbrtein  KvtxdtB 


PROGNOSIS.* 


BY  PAUL  H.   RINGER,  A.B.,   M.D.,  ASHEVILLE,   N.  C. 


Every  physician  is  asked  upon  his  initial  visit  to  every  patient 
two  questions:  "What  is  the  matter?"  and  "What  is  going  to 
happen?"  Thus  at  once  he  is  requested  to  give  utterance  to  his 
diagnosis  and  to  his  prognosis.  It  is  noteworthy  that  so  much 
more  attention  has  been  given  to  diagnosis  than  to  prognosis  in 
modern  times.  W^hole  Hbraries  are  to  be  found  deaUng  with  the 
former,  while  books  or  articles  dealing  with  the  latter  are  few 
indeed.  Of  course  a  proper  prognosis  presupposes  an  accurate 
diagnosis ;  yet  all  physicians  are  again  and  again  forced  to  form- 
ulate a  prognosis  without  having  an  absolutely  accurate  diagnosis 
very  clearly  in  mind.  Among  the  laity  physicians  are  famous, 
if  not  infamous,  for  their  unwillingness  to  commit  themselves, 
and  this  reputation  rests  unquestionably  upon  the  matter  of  prog- 
nosis. No  man  wishes  to  go  on  record  as  an  absolute  positivist 
in  a  matter  in  which  there  is  such  liability  to  error  as  prognosis. 
Hence,  the  "may,"  the  "but,"  the  "if,"  all  of  which  go  to  make 
prognosis  one  of  the  most  proficient  examples  of  "the  gentle  art 
of  hedging." 

It  is  a  far  cry  from  the  "Prognostics"  of  Hippocrates  to  Eis- 
ner's "Prognosis  of  Internal  Disease"  issued  but  a  few  months 
ago,  and  to  the  credit  of  the  Master  of  Medicine  is  it  that  many 
of  his  observations  and  forecasts  hold  good  today  over  the  lapse 
of  twenty-five  centuries  and  at  a  time  when  advances  and  discov- 
eries in  medicine  succeed  one  another  with  tremendous  rapidity. 
The  "Hippocratic  facies"  foretell  impending  death  as  accurately 
today  as  it  did  when  Hippocrates  first  described  them:    "From 


*Read  before  the  Buncombe  County  (N.  C.)   Medical  Society,  February 
5,  1917. 


170     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

a  spitting  of  blood  there  comes  a  spitting  of  pus"  (a  prognostic 
statement)  is  today  universally  recognized,  and  none  but  the  fool- 
ish will  go  contrary  to  the  dictum  "in  acute  disease  it  is  not  quite 
safe  to  prognosticate  either  death  or  recovery."  The  ancients 
devoted  far  more  study  to  the  question  of  prognosis  than  do  we, 
but  their  prognostics  were  based  almost  exclusively  on  symptoms. 
On  reading  the  works  of  Hippocrates,  one  is  struck  with  the  mass 
of  symptoms  observed,  and  the  different  prognostic  value  at- 
tached to  each,  a  value  far  in  excess  of  that  which  is  given  today. 
The  ancients,  however,  used  to  the  extreme  limit  the  value  of  the 
data  to  be  determined  by  observation.  Having  no  pathology,  no 
physiology  save  of  the  crudest  (and,  as  we  now  know,  falsest) 
nature,  no  conception  of  bacteriology  or  immunity,  it  is  but  nat- 
ural that  symptoms  formed  the  foundation,  edifice  and  super- 
structure of  all  their  prognostic  conclusions.  Having  but  ele- 
mentary modes  of  treatment,  many  of  them,  as  we  now  know, 
based  on  false  premises  and  incapable  of  doing  good,  the  ancients 
could  consider  but  very  slightly  the  effect  of  treatment  on  disease. 
So,  all  honor  to  the  sober,  earnest  and  observant  pioneers  in  med- 
icine who,  despite  their  slender  knowledge  and  awful  handicaps, 
were  able  to  lay  down  so  many  fundamental  laws  that  have  lasted 
to  this  day,  and  that  will  survive  as  long  as  man  continues  mortal. 

The  nature  of  modern  prognosis  is  radically  different  from 
that  of  ancient  prognosis.  Having  at  our  command  a  well 
worked-out  system  of  physiology,  an  ever-increasing  knowledge 
of  pathology,  countless  laboratory  facilities  for  demonstrating  the 
condition  of  the  various  organs  and  systems  of  the  body  as  well 
as  other  procedures  for  estimating  their  functional  capacities, 
having  the  knowledge  gained  at  the  operating  table  and  at  the 
necropsy  room,  we  are  in  a  far  better  position  to  make  an  accu- 
rate and  precise  diagnosis.  Upon  this  as  a  basis  must  of  neces- 
sity be  grounded  our  forecast  of  the  future.  Hence,  in  contra- 
distinction to  the  symptomatological  prognosis  of  the  ancients, 
modern  prognosis  is  essentially  based  on  diagnosis. 

Furthermore,  with  the  many  agencies  at  our  command,  prog- 
nosis can  not  be  considered  apart   from  treatment.     We  have 


SELECTED  ARTICLES  171 

passed  the  time  when  we  can  say,  as  our  predecessor  of  one  hun- 
dred and  fifty  years  ago  did : 

"First  I  bleeds  'em, 
Then  I  sweats  'em, 
Then,  if  they  wants  to  die, 
I  lets  'em." 

Who  is  there  that  can  formulate  a  prognosis  in  a  case  of  ap- 
pendicitis with  rupture  and  leave  out  of  consideration  surgical 
interference?  Or  who  can  consider  the  outlook  in  diphtheria  with- 
out taking  into  consideration  the  administration  of  antitoxin? 
It  may  be  said  that  extreme  instances  have  been  chosen;  true 
enough,  but  such  and  such  only  will  stress  the  point  sufficiently. 
Our  forefathers  had  but  little  of  the  therapeutic  armamentarium 
that  we  now  possess,  and  still  less  of  an  accurate  knowledge  of 
conditions  with  which  they  were  dealing.  Thus,  with  us,  prog- 
nosis becomes  an  infinitely  more  complicated  question  when  dealt 
with  from  the  dual  viewpoint  of  diagnosis  and  therapeutics  than 
from  the  single  standpoint  of  symptomatology.  The  nature  of 
modern  medicine  is  to  attempt  to  bring  it  more  and  more  into  the 
domain  of  science,  to  attain  as  nearly  as  possible  to  the  absolute, 
and  to  rely  as  little  as  possible  upon  the  variable.  However  praise- 
worthy this  trend  may  be  (and  praiseworth  it  is,  as  it  has  as  its 
object  the  attainment  of  exact  knowledge  concerning  all  man- 
ner of  human  ills),  the  final  goal  is  unattainable,  and  from  the 
very  nature  of  the  material  with  which  their  protean  character- 
istics, resistive  powers,  susceptibilities,  etc.,  the  art  of  medicine 
will  ever  remain  a  most  important  element  in  practice. 

This  argument  brings  us  by  but  a  short  step  to  the  question  of 
the  nature  of  prognosis.  Is  it  a  science  or  an  art?  Unquestion- 
ably, an  admixture  of  both,  but,  save  in  isolated  instances,  the 
art  of  foretelling  the  future  will  ever  overshadow  the  science  of 
prophecy.  When  all  is  said  and  done,  after  the  taking  of  the 
most  careful  history,  the  completion  of  the  most  searching  phys- 
ical examination,  the  correlation  of  the  most  diverse  and  minute 
laboratory  tests,  the  physician  must  over  and  above  these  add 
thereto  the  fruits  of  his  own  experience,  his  knowledge  of  the 


172     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

"constitution"  of  the  patient,  his  intuition,  all  of  which — for  rea- 
sons in  the  main  empiric — inspire  him  with  hope  or  with  despair. 
These  latter  factors  can  never  be  gauged  by  an  instrument  of  pre- 
cision nor  can  their  value  be  expressed  in  terms  of  quantity,  but 
their  importance  is  beyond  measure  and  to  their  still  small  voices 
will  the  man  of  experience  give  keen  attention. 

Men  are  by  nature  either  optimists  or  pessimists,  and  physi- 
cians, being  men,  must  belong  to  one  of  these  two  groups.  Every 
true  physician  should  be  an  optimist,  for  only  by  walking  through- 
out his  own  life  on  "the  sunny  side  of  the  street"  can  he  expect 
to  dissipate  the  gloom  with  which  he  is  daily  brought  in  contact. 
The  prognosis  the  physician  gives  must  be  in  a  measure  influenced 
by  his  temperament,  for  the  effects  of  physical  conditions  upon 
our  minds  is  largely  influenced  by  the  color  of  the 
glasses  through  which  we  view  the  world.  An  optimistic  prog- 
nosis at  least  to  the  patient  is  almost  an  essential.  The  question 
comes  up  again  and  again  as  to  the  advisability  of  telling  the 
truth  to  patients  fatally  ill.  It  is  but  very  rarely  necessary  to 
directly  tell  a  patient  that  he  will  die.  Sometimes,  in  the  case  of 
men  with  important  business  matters  to  arrange,  the  plain  facts 
must  be  told.  Relatives  of  the  patient  should  always  be  informed 
as  to  the  true  state  of  his  condition,  that  they  may  both  be  pre- 
pared, and  realize  that  the  physician  appreciates  the  gravity  of 
the  situation.  Even  to  them  should  be  accentuated  the  fallibility 
of  human  knowledge,  and  every  vestige  of  hope  should  not  be 
withdrawn. 

Shall  the  physician  tell  a  deliberate  falsehood  to  his  patient 
that  is  not  going  to  recover?  It  is  well  to  avoid  being  too  posi- 
tive on  the  side  of  recovery,  but  the  brightest  possible  side  of  the 
picture  must  be  presented  to  the  patient.  We  must  remember 
that  while,  in  the  words  of  Hippocrates,  "All  the  sick  can  not  get 
well,"  our  part  is  to  soothe  mental  and  physical  anguish,  to  mini- 
mize pain,  to  comfort  and  sustain  our  failing  patients  as  well  as 
to  cure  disease.  The  cheery  smile,  the  brightening  word,  the 
tang  of  virility  and  strength  in  the  physician  go  far  to  cheer  and 
reinforce  the  patient.  And  if,  after  all,  death  is  to  come,  let  it 
come  to  those  for  whom  we  care,  finding  them  fighting,  not  think- 


SELECTED  ARTICLES  178 

ing  of  defeat,  but  ever  hoping,  even  against  concrete  evidence, 
for  improvement.  By  so  doing  we  are  rendering  the  best  service 
possible  to  our  patient,  and,  in  a  very  small  percentage  of  cases, 
we  will  turn  apparently  certain  defeat  into  relative  or  complete 
victory.  For  an  optimistic  prognosis  is  to  a  trusting  patient  the 
most  powerful  suggestion  possible,  and  who  is  there  that  will 
deny  the  right,  nay,  the  bounden  duty,  of  every  physician  to  make 
use  of  this  psychic  aid  to  recovery  from  organic  disease? 

The  effect  of  an  unfavorable  prognosis  upon  the  patient  may 
vary  all  the  way  from  loss  of  faith  in  the  physician  making  the 
prognosis  to  suicide,  and  we  have  all  seen  both  extremes.  Of 
course,  blind  optimism  in  the  presence  of  a  positive  diagnosis  of 
serious  disease  is  akin  to  malpractice  and  can  but  result  in  untold 
harm.  The  patient  with  tubercle  bacilli  in  his  sputum  must  not 
be  dismissed  with  a  cough  mixture  and  the  assurance  that  he 
merely  has  a  slight  bronchial  affection ;  the  individual  with  a  car- 
cinomatous ulcer  on  the  tongue  must  not  be  allowed  to  go  with 
the  advice  to  "stop  smoking  and  it  will  clear  up."  But  while  the 
patient  must  be  made  to  realize  the  gravity  of  the  condition  and 
the  necessity  for  proper  therapeutic  measures,  we  must  endeavor 
to  "temper  the  wind  to  the  shorn  lamb." 

Finally,  we  must  realize  that  the  prognosis  made  has  a  decided 
influence  upon  the  physician  that  makes  it.  Before  our  own  eyes 
we  must  keep  the  candle  of  hope  alight  that,  by  its  auto-sugges- 
tive action,  our  labors  may  be  stimulated.  Once  having  made  an 
absolutely  bad  prognosis  in  a  given  case,  we  are  almost  invariably 
assailed  by  the  thought,  "What's  the  use?"  and  ever  afterward 
we  treat  that  patient  with  a  lessened  enthusiasm  and  with  less 
keen  professional  skill  because  of  our  loss  of  faith  in  ourselves. 
We  must  bear  in  mind  our  own  fallibility  and  we  must  recall  the 
cases  in  which  we  have  been  mistaken  and  in  which,  if  not  re- 
covery, at  any  rate  marked  improvement  has  followed  our  hope- 
less forecast.  The  man  that  has  lost  faith  in  himself  has  likewise 
lost  faith  in  all  else  as  well,  and  it  is  in  order  to  buoy  up  our  own 
failings  and  fallible  selves  that  we  must  not  allow  all  hope  to 
depart. 


174     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Thus  we  see  that  prognosis  as  here  reviewed  is  essentially  an 
art,  one  in  which  the  conscientious  and  capable  physician  must 
not  exclude  the  cold,  absolute  facts  of  science;  one  in  which  he 
must  be  honest  with  himself  and  fair  to  his  patient,  seeing  mat- 
ters in  their  true  light,  and  when  that  light  is  all  grey,  giving  to 
the  patient  that  spark  of  life  which,  though  perhaps  ill-founded, 
springs  from  a  desperate  and  heartfelt  wish  on  the  part  of  the 
doctor  that  he  may  be  in  the  wrong,  and,  in  the  expression  of 
that  wish,  stretching  forth  the  hand  of  friendship  and  of  help  to 
a  fellow-being  for  so  long  a  time  as  that  hand  can  be  held. — Vir- 
ginia Medical  Semi-Monthly. 


EXTRACTS  FROM  JOURNALS  176 


Extracts  from  ^amt  anb  Wonx^n  Journala 


SURGICAL 


Fracture  of  Trapezoid. 


A  Mouchet.  Presse  Med..  October  9.  1916,  reports  a  case  in  a 
female  weaver,  aged  30,  who  was  suddenly  incapacitated  while 
lifting  a  heavy  bolt  of  cloth  with  the  hand  strongly  flexed  (50 
kilos,  with  assistant  lifting  at  each  end  of  the  bolt).  A  transverse 
fissure  of  the  trapezoid  alone  was  found  radiographically,  with 
a  sort  of  dorsal  eversion  of  the  fragments.  Warm  bathing  and 
a  retentive  dressing  with  a  soft  w-ad,  resulted  in  healing  in  three 
weeks,  but  with  an  osseous  projection  on  the  dorsal  aspect  of  the 
trapezoid.  He  considers  isolated  fracture  of  this  bone  as  unique. 
— Buffalo  Medical  Journal. 


A  Bullet  in  the  Sphenoidal  Sinuses. 


Capt.  H.  Elwin  Harris.  F.R.C.S.,  Beufort  War  Hospital  (The 
Lancet,  December  9,  1916).  A  soldier,  aged  22,  while  being 
dressed  for  a  wound  over  the  left  hip,  was  struck  a  second  time 
and  rendered  unconscious.  On  recovering  consciousness,  blood 
was  found  trickling  down  the  nose  from  the  inner  canthus  of  the 
left  eye.  On  arrival  at  the  hospital  no  wound  or  scar  could  be 
found  either  on  the  face  or  scalp,  although  there  were  swelling 
and  paralysis  of  the  eyelids  and  optic  atrophy  on  the  left  side. 
Skiagrams  showed  "a  bullet  lying  transversely  and  obliquely  be- 
low the  sella  turcica;  its  base  was  seen  in  the  left  sphenoidal  sinus 
and  the  body  passed  oliquely  downwards  and  forw^ards  through 
the  septum  between  the  sinuses,  its  nose  resting  in  the  roof  of 
the  right  nasal  cavity."  The  author  thinks  that  the  bullet  en- 
tered at  the  left  inner  canthus,  passed  along  between  the  eyeball 
and  the  inner  wall  of  the  orbit  to  the  apex  where  it  turned  an 


176     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

angle  of  more  than  180  degrees  and  entered  the  sphenoidal  sinus, 
wounding  the  optic  and  third  nerves  along  the  way. 

The  author  describes  his  method  of  removal  of  the  bullet,  which 
was,  briefly,  as  follows:  He  first  removed  the  anterior  half  of 
the  inferior  and  most  of  the  middle  turbinates  from  the  left  nos- 
tril. Later  he  broke  through  the  anterior  wall  of  the  sphenoidal 
sinus,  but  was  unable  to  get  the  bullet.  Finally,  with  the  patient 
under  a  general  anesthetic  on  the  X-ray  table,  he  succeeded  in 
cutting  away  the  remains  of  the  anterior  sphenoidal  wall  and 
removing  the  bullet  with  a  blunt  hook.  Recovery  was  uneventful. 
— Pacific  Medical  Journal. 


Carcinoma  of  Breast. 


On  August  18,  1916,  patient,  L.  M.,  colored,  female,  came  to 
me  with  the  following  history :  Has  had  for  some  years  a  growth 
involving  the  breast,  near  the  nipple,  for  which  she  had  not  re- 
ceived medical  attention,  but  had  treated  it  with  poultices  and 
other  lay  methods.  When  I  saw  her  the  nipple  was  practically 
covered  by  a  large  slough.  The  breast  was  freely  movable  over 
the  chest  wall,  and  in  the  axilla  could  be  felt  a  number  of  firm 
glandular  nodules.    Operation  was  advised  and  carried  out. 

The  most  interesting  feature  of  this  case  is  the  method  which 
was  employed  to  prevent  contamination  of  the  wound  from  the 
ulcerated  area.  By  enveloping  the  breast  in  gauze  and  pinning 
it  down  with  forceps  hooked  into  the  skin,  we  were  able  to  pro- 
tect the  field  of  operation  in  a  very  satisfactory  manner.  I  be- 
lieve, however,  that  a  sheet  of  rubber  over  this  gauze  would  have 
added  to  the  protection. 

Incision  was  made  in  the  usual  manner.  Of  course,  we  han- 
dled the  breast  just  as  little  as  possible.  The  axilla  was  dissected 
free  of  glands  and  the  wound  closed,  and,  in  spite  of  the  presence 
of  this  infected  area,  primary  healing  took  place. 

To  my  mind,  this  case  serves  to  emphasize  the  fact  that  the 
laity  in  general,  and  particularly  the  colored  portion  of  our  popu- 
lation, are  densely  ignorant  concerning  the  danger  of  growths  of 


EXTRACTS  FROM  JOURNALS  177 

the  breast ;  yet,  at  the  same  time,  they  have  such  a  dread  for  can- 
cer that  they  conceal  the  fact  that  they  have  a  growth  of  the 
breast  until,  in  many  instances,  the  time  for  successful  interven- 
tion has  passed. — Mississippi  Valley  Medical  Journal. 


MBDICAL 


Septic  Sore  Throat. 


G.  W.  Henika,  M.D.,  amd  I.  F.  Thompson,  M.D.,  in  the  Jour- 
nal of  The  American  Medical  Association,  Vol.  LXVIII,  No.  18, 
give  an  interesting  account  of  an  epidemic  of  septic  sore  throat 
in  Galesville,  Wis.  The  epidemic  lasted  from  February  26  to 
March  19,  1917,  and  324  people  out  of  a  population  of  941  were 
attacked  with  nine  deaths.  The  contagion  was  milk-borne  and 
the  source  was  found  in  six  cows  in  one  dairy,  the  epidemic  being 
ended  by  the  segregation  of  the  six  cows  and  the  instruction  of 
the  citizens  to  boil  all  milk  and  water.  Only  two  cases  could  be 
classed  as  contacts. 

The  conclusion  of  the  authors  that  "this  epidemic  furnishes 
additional  proof  that  pasteurization  of  bottled  milk  under  official 
supervision  is  the  only  method  of  securing  a  safe  milk  supply," 
is  a  fact  that  can  not  be  too  strongly  indorsed. 


The  Effect  of  Cold  on  Malarial  Parasites. 


Experiment  has  demonstrated  that  many  micro-organisms  are 
far  less  sensitive  to  low  temperatures  than  was  believed  to  be 
probable  in  the  earlier  days  of  bacteriology,  in  view  of  the  per- 
manent damage  or  death  which  promptly  ensues  when  the  envir- 
onmental temperature  of  these  lowest  forms  of  life  is  raised.  The 
detrimental  effects  of  heat  have  not  found  a  counterpart  in  the 
influence  of  cold.  Some  bacterial  species  are  known  to  survice 
temperatures  far  below  those  of  the  extreme  cold  occurring  in 
nature.     The  possibility  of  a  survival  of  other  lower  forms,  such 


178     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

as  the  Plasmodia,  under  the  adverse  conditions  represented  by 
low  temperature,  has  not  in  the  past  been  equally  well  investi- 
gated. King,  the  government  entomologist,  has  stated  that  the 
impression  is  gained  from  the  literature  on  malaria  that 
the  development  of  malaria  parasites  in  Anopheles  is  arrested 
at  a  temperature  of  about  60  F.  and  that  the  parasites  themselves 
are  destroyed  at  temperatures  below  this.  He  recognizes  the 
importance  of  the  question,  since  it  involves  the  survival  of  in- 
fection in  mosquitoes  after  hibernation  or  after  exposure  to  low 
temperatures  under  natural  conditions.  In  new  experiments  con- 
ducted in  the  Tulane  University  Aledical  Department  at  New  Or- 
leans, King  has  found  that  the  parasite  of  tertian  malaria  in  the 
mosquito  host  is  able  to  survive  exposure  to  a  temperature  of  30 
F.  for  a  period  of  two  days,  31  F.  for  four  days,  and  a  mean 
temperature  of  46  F.  for  seventeen  days.  In  a  smaller  series  of 
tests  the  sporonts  of  the  estivo-autumnal  parasite  have  shown  a 
resistance  to  temperatures  as  low  as  35  F.  for  twenty-four  hours. 
This  demonstration  of  the  resistance  of  Plasmodium  vivax  and 
Plasmodium  falciparum  to  cold  and  survival  through  a  freezing 
temperature  of  several  days'  duration  is  significant. — The  Journal 
of  the  American  Medical  Association. 


OHSTETRICAL. 


Resuscitation  of  Apparently  Dead  Infant. 


Last  summer  I  was  called  to  attend  a  case  of  midwifery  in  the 
Mellow  \"alley  from  a  distance  of  65  miles  from  Waterville.  I 
got  there  five  minutes  after  the  baby  was  born.  Found  the  cord 
had  been  prolapsed  for  fifteen  to  twenty  minutes  before  birth 
and  the  babe  was  apparently  dead,  eyes  rolled  back  and  no  sign 
of  heart  beat  by  careful  auscultation. 

I  immediately  whipped  out  my  hypodermic  syringe  and  gave 
it  one-half  cc.  of  pituitrin  in  the  left  hip,  followed  by  immersion 
in  a  bath  of  warm  water  up  to  the  chin  and  commenced  traction 
on  the  tonsfue.     In  fifteen  minutes  I  listened  to  chest  and  heard 


EXTRACTS  FROM  JOURNALS  179 

the  heart  give  a  distinct  impulse.  Fifteen  minutes  later  I  gave 
it  1-240  gr.  strychnine  in  the  other  hip.  Listened  to  heart  and 
counted  an  impulse  of  15  to  the  minute.  In  two  hours  gave  a 
small  dose  of  digitalin  in  shoulder.  Counted  pulse  about  this 
time  and  heart  beat  was  130  per  minute.  The  babe  cried  lustily 
in  the  meantime  and  I  handed  it  over  to  its  mother  to  nurse. 

Someone  in  like  circumstances  may  find  this  interesting.  This 
is  not  original  as  I  read  of  a  case  of  a  woman  dead  before  child 
was  delivered,  where  pituitrin,  injected  in  the  stump  of  navel, 
started  its  heart  beating. — Northzi<est  Medicine,  April,  1917. 


The  Action  of  Ver.\trone  in  the  Treatment 
OF  Eclampsia. 


In  the  Edinburgh  Medical  Journal  for  December,  Haultain 
concludes  from  its  use  that  it  may  be  stated  that  we  have  in 
veratrone  a  drug  of  the  utmost  value  in  the  treatment  of  eclamp- 
sia, as  shown  by  its  success  in  the  treatment  of  thirty-eight  con- 
secutive cases.  After  the  initial  dose  of  1  Cs.  subsequent  doses 
should  be  regulated  by  the  blood-pressure  of  the  patient,  as  by 
so  doing  it  can  be  given  with  safety  and  to  the  greatest  advantage. 
— The  Therapeutic  Gazette. 


Antisyphilitic  Treatment  of  Pregnant  Women. 


Cons  relates  that  of  five  pregnant  women  with  unsuspected 
syphilis,  only  two  bore  viable  children  and  one  of  these  soon  died. 
The  other  woman  had  been  given  a  dose  of  salvarsan  twelve  days 
before  delivery  and  this  child  left  the  hospital  apparently  in  good 
condition.  Fourteen  other  pregnant  women,  mostly  in  the  second 
stage  of  their  syphilis,  were  given  specific  treatment  during  the 
pregnancy  and  all  bore  viable  children.  One  child  died  a  month 
later  from  a  congenital  heart  defect;  the  others  are  all  apparently 
in  perfect  health. — The  Journal  of  the  American  Medical  Asso- 
ciation. 


180     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


Siitorial 


PUBLISHER'S  NOTICE — The  Journal  is  published  in  monthly  numbers  of 
48  pages  at  $1.00  a  year,  to  be  always  paid  in  advance. 

All  bills  for  advertisements  to  be  paid  quarterly,  after  the  first  insertion  of 
the  quarter. 

Business  communications,  remittances  by  mail,  either  by  money  order, 
draft,  or  registered  letter,  should  be  addressed  to  the  Business  manager,  C. 
S.  Briggs,  M.D.,  corner  Summer  and  Union  Streets,  Nashville,  Tenn. 

All  communications  for  the  Journal,  books  for  review,  exchanges,  etc., 
should  be  addressed  to  the  Editor. 


Fees. 

While  the  practice  of  both  medicine  and  surgery  has  been 
revolutionized  in  the  last  six  or  seven  decades,  there  has  been  lit- 
tle, if  any,  change  in  fees.  Surgical  fees  are  still  large,  medical 
fees  still  small. 

Before  the  days  of  anesthetics,  antisepsis  and  asepsis  and  ab- 
dominal surgery,  surgeons  were  few  and  far  between,  and  few 
states  could  boast  of  many.  Patients  had  to  travel  miles  to  reach 
the  nearest,  not  necessarily  the  best,  surgeon,  and  a  surgeon's 
clientele,  in  spite  of  the  inconvenience  of  travel,  was  oftentimes 
as  large  in  neighboring  states  as  in  his  own.  Surgeons  were 
scarce  because  it  required  an  iron  nerve  to  operate  on  a  strug- 
gling, suffering  patient,  constantly  slipping  from  under  the  knife 
in  spite  of  ropes,  straps  and  strong  assistants;  it  also  required 
courage  to  meet  the  inevitable  postoperative  complications,  such 
as  shock  and  suppuration,  sepsis  and  hemorrhage;  furthermore, 
it  took  courage  to  operate  when  public  sentiment  was  against  op- 
eration and  when  death  nearly  always  held  the  best  cards  in  the 
deck.  But  owing  to  the  courage  of  those  who  chose  surgery, 
marvelous  advances  have  been  made,  and  many  of  the  barriers, 
which  held  in  check  the  enthusiasm  of  young  graduates  for  this 
very  interesting  branch  of  practice,  have  been  lowered.  Today 
surgeons  are  no  longer  scarce,  on  the  contrary  their  number  is 
legion.  The  number  of  surgeons,  good  surgeons,  is  so  great  to- 
day, that  many  of  them  would  starve  to  death  were  surgical  cases 


EDITORIALS  181 

as  few  today  as  fifty  years  ago.  Such,  however,  is  not  the  case, 
for  the  internists  have  generously  turned  over  first  one  organ 
then  another  until  today  the  surgeon  has  most  of  the  body  all 
his  own,  and  what  he  has  not,  he  is  trying  his  best  to  get.  Even 
the  diseases  which  can  not  possibly  become  surgical  are  being 
torn  from  the  internists'  care  by  the  scientific  study  of  epidem- 
iology of  diseases,  improved  rural  and  municipal  sanitation  and 
public  education  in  regard  to  the  spread  of  diseases. 

Improved  therapeusis,  even  though  he  administers  it  himself, 
reduces  his  income,  and  the  diminishing  birth  rate  robs  him  of 
many  obstetrical  fees,  which,  though  ridiculously  small,  are  nev- 
ertheless large  in  proportion  to  his  usual  fees.  And  to  cap  the 
climax,  comparatively  few  surgeons  restrict  their  practice  to  sur- 
gery, so  that  here  again  the  internist  is  the  loser. 

The  above  brief  citation  of  facts  does  not  tell  the  whole  story 
but  is  sufficient.  We  do  not  say  that  surgical  fees  should  be  low- 
ered, but  we  feel  that  internists  should  increase  theirs,  since  oth- 
erwise internal  medicine  is  doomed  to  retrogress  from  lack  of 
good  men  in  that  particular  branch  of  practice. 


Better  Sanit.\tion  Needed  in  Rural  Schools. 


In  the  interests  of  efficiency  and  health  there  is  increasing  ne- 
cessity for  the  application  of  scientific  medical  and  sanitary  knowl- 
edge to  the  administration  of  the  public  schools,  in  the  opinion  of 
the  Public  Health  Service. 

In  general,  the  faults  observed  in  rural  schools,  the  annual  re- 
port of  the  Service  declares,  are  due  to  a  lack  of  skilled  advice, 
especially  in  regard  to  the  location,  construction  and  equipment 
of  school  buildings  and  disregard  of  sanitary  principles  govern- 
ing water  supplies,  the  disposal  of  sewage,  ventilation,  tempera- 
ture, illumination,  and  the  arrangement  of  school  desks  and 
blackboards.  During  the  past  fiscal  year  surveys  have  been  made 
in  rural  districts  of  several  states  and  many  thousand  school  chil- 
dren have  been  examined.  These  examinations  have  included 
thorough  testing  of  the  eyes  by  competent  oculists,  tests  of  men- 


182     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

tal  capacity,  and  the  effect  of  sanitary  environment  on  school 
progress,  as  well  as  inspections  for  the  customary  physical  de- 
fects. 

The  conclusion  is  reached  that  there  is  great  need  for  improve- 
ment in  rural  schools  and  that  communities  themselves  will  benefit 
if  conditions  are  bettered,  the  schools  serving  as  object  lessons 
for  surrounding  sections.  Conditions  in  country  districts  have 
been  found  below  those  in  the  cities,  and  it  is  apparent  that  or- 
ganized health  work  has  largely  been  confined  to  the  latter.  Con- 
sidered from  a  sanitary  standpoint  alone  the  Public  Health  Ser- 
vice is  in  favor  of  the  consolidation  of  rural  schools,  since  it  must 
eventually  result  in  the  providing  of  better  buildings  and  the  or- 
ganization of  systems  of  efficient  sanitary  inspections. 


Accurate  Concepts  in  Electronic  Diagnosis. 


In  the  last  issue  of  the  classical  quarterly,  "The  International 
Clinics,"  there  appeared  a  contribution  by  Dr.  Albert  Abrams 
(AM.  LLD.  M.D.,  Heidelberg,  F.  R.  M.  S.)  of  San  Francisco, 
bearing  on  the  subject,  "The  Electronic  Reactions  of  Abrams." 

This  is  perhaps  one  of  the  most  radical  attempts  ever  made  in 
medicine  and  in  diagnosis.  It  is  based  on  the  fact  recognized  by 
physicists  that,  the  ultimate  constituent  of  the  body  is  the  electron 
and  not  the  cell. 

These  electrons  in  their  incessant  activity  create  a  field  of 
radio-activity  which  always  has  a  definite  rate  of  vibration. 

Unfortunately  there  are  no  instruments  of  sufficient  sensitivity 
to  enable  one  to  detect  these  radiations. 

The  discoverer  of  radium  demolished  precipitously  the  estab- 
lished theories  of  matter  and  force  so  that  chemistry  was  forced 
to  be  rewritten  and  our  conception  of  this  constituent  of  matter 
completely  changed. 

Abrams  has  found  that  the  reflexes  bearing  his  name  and 
which  have  been  fully  exploited  in  the  last  volume  of  "The  Ref- 
erence Handbook  of  the  Medical  Sciences"  are  so  sensitive  that 
they  can  be  utilized  in  the  diagnosis  of  disease.     Not  only  is  it 


EDITORIALS  188 

possible  to  diagnose  disease  with  mathematical  accuracy,  but  one 
can  measure  with  the  same  precision  the  virulency  of  affection. 
These  methods  have  revolutionized  the  early  diagnosis  of  cancer, 
tuberculosis,  syphilis  and  other  diseases.  Thus  we  are  able  to 
say  how  different  antisyphilitic  treatment  is  when  it  is  necessary 
and  how  long  to  continue  it. 

In  a  recent  communication  by  George  O.  Jarvis,  A.  B.  M.  D., 
formerly  of  the  University  of  Pennsylvania,  he  found,  that  the 
electronic  tests  of  Abrams  was  positive  in  nearly  100  per  cent  of 
syphilitic  infections,  whether  they  were  hereditary  or  acquired. 

Another  important  feature  of  Abrams'  tests  is  the  ability  to 
recognize  congenital    from   acquired   syphilis. 

The  reaction  in  syphilis  like  in  other  diseases,  is  always  present. 

Another  feature  of  these  reactions  is  the  fact  that  a  diagnosis 
may  be  accurately  made  from  the  blood.  The  discoverer  of  these 
methods  is  most  anxious  to  introduce  them  to  the  medical  pro- 
fession and  he  invites  correspondence  with  relation  to  the  same. 
Specimens  of  blood  sent  to  him  and  placed  on  a  slide  or  paper  will 
be  gratuitously  examined  and  reported  on  by  him. 

Any  physician  of  sufficient  intelligence  may  learn  these  meth- 
ods provided  he  is  capable  of  recognizing  by  percussion  an  area 
of  dullness,  and  Dr.  Abrams  is  most  anxious  to  aid  the  profes- 
sion in  the  interpretation  of  his  methods. 

Physicians  are  accordingly  invited  to  write  Dr.  Albert  Abrams, 
2135  Sacramento  St.,  San  Francisco,  Cal.,  for  both  a  blood  test 
and  further  information  concerning  his  diagnosis  methods. 


Officers  of  the  American  Medical  Association. 


At  the  recent  meeting  of  the  American  Medical  Association  in 
New  York  City  the  following  officers  were  elected : 

President,  Dr.  Arthur  Dean  Bevan  of  Chicago;  First  Vice 
President,  Dr.  Edward  H.  Bradford  of  Boston;  Second  Vice 
President,  Dr.  John  McMullin,  U.  S.  Public  Health  Service; 
Third  Vice  President,  Dr.  Lawrence  Litchfield,  Pittsburgh ;  Sec- 
retary, Dr.  Alexander  C.  Craig,  of  Chicago ;  Treasurer,  Dr.  Wil- 


184     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Ham  Allen  Pusey  of  Chicago;  Chairman  of  the  House  of  Dele- 
gates, Dr.  Hubert  Work  of  Pueblo,  Colo.;  Vice  Chairman,  Dr. 
Dwight  H.  Murray  of  Syracuse,  N.  Y. ;  Trustees,  Dr.  Philip 
Murne  of  Atlantic  City;  Dr.  W.  T.  Sarles  of  Sparta,  Wis.;  Dr. 
Bert  Ellis  of  California  and  Dr.  Wendell  C.  Phillips  of  New  York 
City.    Next  place  of  meeting,  Chicago. 


Do  You  Know  That 


Peace  hath  her  health  problems  no  less  than  war? 

Constant  vigilance  is  the  price  of  freedom  from  flies? 

The  physical  vigor  of  its  citizens  is  the  Nation's  greatest  asset? 

Idleness  is  the  thief  of  health? 

Infected  towels  spread  eye  diseases? 

Half  the  blindness  in  the  world  could  have  been  prevented  by 

prompt  and  proper  care  ? 


American  Medical  Editors  Association. 


This  Association  held  its  forty-ninth  annual  meeting  at  the 
Hotel  McAlpin,  New  York  City,  June  4  and  5.  Owing  to  the 
absence  of  the  president.  Dr.  George  M.  Piersol  of  Philadelphia, 
due  to  his  having  been  called  to  military  duty  at  Fort  Oglethorpe, 
the  vice  president,  Dr.  George  W.  Kosmak  of  New  York,  pre- 
sided. Among  the  resolutions  adopted  by  the  Association  were 
the  following:  Resolved,  that  the  members  of  this  Association 
pledge  themselves  to  publish  prominently,  at  least  three  times 
within  the  following  three  months,  a  copy  of  the  official  personal 
application  blank  with  an  explanatory  comment  on  the  proper 
procedure  to  be  employed  in  transmitting  the  same  to  the  Sur- 
geon General's  office.  Resolved,  that  all  medical  journals  in  this 
country  be  urged  to  present  editorially  the  needs  of  the  military 
services  in  this  crisis  and  the  immediate  necessity  for  securing 
the  full  complement  of  medical  officers  for  the  same.  An  appro- 
priation of  $250  was  made  for  carrying  out  the  provisions  of  this 


EDITORIALS  185 

resolution.  Resolutions  were  also  adopted  providing  for  the  ap- 
pointment of  a  committee  to  be  known  as  the  Food  Resources 
Committee,  which  should  do  all  in  its  power  to  stimulate  interest 
on  the  part  of  all  the  members  in  a  free  and  full  discussion  of  the 
food  problem  as  time  goes  on.  The  Association  also  voted  to  ex- 
pend $5CX)  for  the  purchase  of  Liberty  Bonds.  The  Association 
further  pledged  itself  to  unlimited  effort  in  stimulating  recruit- 
ing for  the  medical  service  of  the  army,  and  appointed  a  commit- 
tee to  further  this  end.  The  annual  banquet  was  held  at  the  Hotel 
McAlpin  on  the  evening  of  June  5,  at  which  the  speakers  were 
Dr.  Henry  O.  Marcy  of  Boston,  an  ex-president  of  the  Associa- 
tion; Dr.  Joseph  Bloodgood  of  Johns  Hopkins  University,  who 
spoke  on  "The  Duty  of  the  Medical  Man  in  this  Great  National 
Crisis ;"  Major  Robert  E.  Noble  of  the  Medical  Corps  of  the 
United  States  Army,  on  "The  Needs  of  the  United  States  Army;" 
Talcott  Williams,  Ph.D.,  Dean  of  the  School  of  Journalism  of 
Columbia  University,  on  "The  Duty  of  the  Hour,"  and  Dr.  Geo. 
F.  Butler  of  Mudlavia,  Ind.,  on  "The  Ladies."  The  following 
officers  were  elected  for  the  ensuing  year:  President,  Dr.  Geo. 
W.  Kosmak  of  New  York,  editor  of  the  America)!  Journal  of  Ob- 
stetrics, Gynecology  and  Diseases  of  Children;  First  Vice  Presi- 
dent, Dr.  Robert  ^L  Green  of  Boston,  editor  of  the  Boston  Med- 
ical and  Surgical  Journal;  second  vice  president,  Dr.  Scale  Har- 
ris of  Birmingham,  Ala.,  Southern  Medical  Journal;  secretary 
and  treasurer,  Dr.  Joseph  McDonald  of  New  York,  of  the  Amer- 
ican Journal  of  Surgery;  members  of  the  Executive  Committee, 
Drs.  C.  F.  Taylor  of  Philadelphia,  A.  S.  Burdick  of  Chicago,  and 
D.  S.  Fairchild  of  Clinton,  Iowa. 


The  Need  of  Medical  Officers  for  the  Army. 


The  Regular  Army  and  the  National  Guard  are  to  be  increased 
to  their  full  war  strength.  The  selective  draft  has  become  a  law, 
and  in  a  short  time  500,000  men  will  be  in  training.  Twenty 
thousand  medical  officers  are  desired  for  active  service  and  re- 
serve.   About  4,000  have  volunteered.     England  and  France  also 


186      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

require  additional  medical  officers  from  this  country ;  200  a  month, 
it  is  expected,  will  be  sent.  The  need  is  imperative  for  young 
men  with  some  hospital  experience.  The  old  men  have  volun- 
teered, but  young  men  are  wanted.  The  opportunities  for  travel, 
for  service  and  for  gaining  reputation  are  great.  Now  is  the 
time  to  offer  your  services  to  the  country. — Maryland  Medical 
Journal. 


"Hygiene  is  the  art  of  preserving  health ;  that  is,  of  obtaining 
the  most  perfect  action  of  body  and  mind  during  as  long  a  pe- 
riod as  is  consistent  with  the  laws  of  life."  So  wrote  a  man  who 
devoted  all  his  adult  life  to  the  promotion  of  the  public  health 
and  who  died  at  the  age  of  56  of  pulmonary  tuberculosis.  Ed- 
mund Alexander  Parkes,  born  ^larch  29,  1819,  physician,  sur- 
geon, sanitarian  and  author  left  perhaps  a  greater  impress  on 
sanitary  science  than  any  Englishman  of  the  nineteenth  century. 
His  work  ranges  from  the  theoretical  consideration  of  the  min- 
utest details  of  chemical  and  physiological  research  to  the  prac- 
tical consideration  of  the  cleansing  of  a  sewer  or  the  lightening 
of  the  soldiers'  knapsack.  India,  the  Crimea  and  London  saw 
his  labors  and  benefited  thereby. 

War  brings  some  good  things  in  its  train.  Just  as  the  Napo- 
leonic campaigns  perfected  the  art  of  transporting  the  sick,  and 
the  loss  of  life  from  preventable  disease  in  the  Spanish  War 
quickened  the  sanitary  conscience  of  the  American  people,  so  the 
horrors  of  the  Crimean  campaign  made  Parkes  a  professor  of 
military  hygiene.  He  organized  a  complete  course  of  instruction 
based  on  the  principle  that  the  student  must  be  able  to  practically 
apply  the  lessons  which  he  learned.  Many  of  the  sanitary  re- 
forms which  he  inaugurated  are  now  bearing  fruit  in  the  improve- 
ment of  the  well-being  of  the  community  at  large. 

Health  is  the  efficient  reaction  of  the  mind  and  body  to  its  en- 
vironment. Self-interest,  state-benefit  and  pecuniary  profit  re- 
quire that  the  whole  nation  be  interested  in  the  proper  treatment 
of  every  one  of  its  members  and  "in  its  own  interest  it  has  the 
right  to  see  that  the  relations  between  individuals  are  not  such 


EDITORIALS  187 

as  in  any  way  to  injure  the  well-being  of  the  community  at  large." 
This  is  being  realized  in  the  United  States  today  as  never  before, 
and  on  every  hand  the  general  government,  the  State  and  local 
health  authorities  and  the  general  public  are  seen  striving  toward 
the  accomplishment  of  this  ideal. 


We  note  with  deep  regret  the  death  May  16th  of  Dr.  Winslow 
Anderson  of  San  Francisco,  for  a  quarter  of  a  century  editor  of 
the  Pacific  Medical  Journal.  Not  only  as  an  editor  but  as  a  sur- 
geon he  was  highly  esteemed  on  two  continents,  and  as  an  ab- 
dominal surgeon  he  had  iew  equals  and  no  superiors.  His  re- 
moval will  be  acutely  felt  by  the  profession  of  the  West. 


The  deplorable  tragedy  at  Sheffield,  x\la.,  in  which  Dr.  Hugh 
W.  Blair  of  that  city  shot  his  wife  and  then  committed  suicide, 
which  sad  event  took  place  June  13th,  will  be  a  great  shock  to  his 
many  friends  and  admirers.  Dr.  Blair  graduated  from  the  Aled- 
ical  Department  of  Vanderbilt  University  in  1883  and  at  once 
took  rank  as  a  successful  practitioner  in  Sheffield,  the  scene  of 
his  labors  and  of  his  untimely  death. 


Dog  fanciers  have  long  noted  that  when  a  house-dog  begins  to 
get  fat  and  wheezy  it  is  pretty  apt  to  be  attacked  by  a  stubborn 
skin  disease.  In  such  a  case  they  cut  down  the  diet  and  increase 
the  open  air  exercise,  thus  relieving  the  over-burdened  body  of 
poisonous  substances. 

The  sin  of  gluttony  is  common  and  therefore  much  condoned, 
but  like  every  other  violation  of  Nature's  laws  has  a  penalty.  Fat 
inefficiency,  sluggish  mentality,  the  reddened  nose,  the  pimpled 
face,  certain  of  the  chronic  skin  eruptions,  and  much  fatigue  and 
nervousness  are  due  to  the  abuse  of  the  digestive  apparatus.  Rich 
indigestible  foods  in  large  quantities,  highly  seasoned  to  stimulate 
the  jaded  palate,  are  forced  into  the  body  already  rebellious  from 
repletion.  Exercise  is  largely  limited  to  walking  to  and  from  the 
table  and  bodily  deterioration  proceeds  rapidly.     Many  an  over- 


188     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

fed  dyspeptic,  suddenly  dragged  by  the  stem  hand  of  circum- 
stance from  a  life  of  physical  ease  and  plenty  and  forced  to  work 
out  of  doors  suddenly  discovers  that  his  semi-invalidism  has  gone, 
that  a  chronic  skin  derangement  of  many  years  standing  has  dis- 
appeared and  that  a  new  vigor  and  zest  of  life  has  been  given 
him. 

Not  everyone  can  spend  his  whole  time  in  the  open  air  but  a 
certain  amount  of  exercise  and  plain  wholesome  food  in  an 
amount  not  exceeding  the  body's  needs  can  be  had  by  almost 
everyone.  Simple  moderate  diet  and  exercise  make  for  health. 
These  are  not  faddish  food  theories:  They  are  just  plain  com- 
mon sense. 


REVIEWS  AND  BOOK  NOTICES  189 


%rtohiB  anb  Souk  Nottr^B 


Department  of  Commerce,  Bureau  of  the  Census.  Samuel  L.  Rogers,  Direc- 
tor. Mortality  Statistics.  1915.  Sixteenth  Annual  Report.  Washing- 
ton   Government  Printing  Office.     1917. 

This  volume  is  the  sixteenth  annual  report  of  Mortality  Sta- 
tistics prepared  by  the  Bureau  of  the  Census  of  the  government 
of  the  United  States.  The  value  of  such  a  compilation  is  incal- 
culable to  the  statistician.  The  immense  labor  represented  in  the 
work  and  the  accuracy  with  which  figures  of  registration  have 
been  handled  is  worthy  of  the  highest  commendation.  It  shows 
the  death  rate  throughout  the  registration  area  of  the  U.  S.  to  be 
13.5  per  1,000  population,  the  lowest  rate  for  any  year.  Every 
disease  with  its  death  rate  is  carefully  computed.  The  work  is  to 
be  highly  commended  for  its  thoroughness  and  accuracy  and  will 
be  of  great  importance  as  a  work  of  reference. 


Impotence,  Sterility  and  Artificial  Impregnation.  By  Frank  P.  Davis, 
Ph.B.,  M.D.,  Fellow  American  Medical  Association ;  Ex-Secretary  Okla- 
homa State  Board  of  Medical  Examiners ;  Former  Superintendent  Okla- 
homa State  Institution  for  Feeble-Minded;  Author  of  "How  to  Collect 
a  Doctor  Bill;"  "His  Book  of  Poems,"  "The  Physician's  Vest-Pocket 
Reference  Book,"  etc. ;  Formerly  Editor  and  Publisher,  Davis  Magazine 
of  Medicine.    St.  Louis.    C.  V.  Mosby  Co.    1917. 

This  little  book  contains  much  of  interest  for  the  general  prac- 
titioner as  it  deals  with  subjects  only  lightly  touched  upon  in  gen- 
eral textbooks.  The  author  has  made  a  close  study  of  the  sub- 
jects treated  of  and  has  presented  a  book  that  conveys  a  great 
deal  of  valuable  information  in  small  compass.  Our  readers  can 
get  a  good  idea  of  the  scope  of  the  work  from  the  contents. 
Chapter  1,  The  Sexual  Instinct;  Chapter  2,  The  Sense  of  Smell; 
Chapter  3,  The  Voice  and  Sense  of  Hearing;  Chapter  4,  The 
Sense  of  Sight ;  Chapter  5,  Impotency ;  Chapter  6,  Psychic  Impo- 
tency ;  Chapter  7,  Masturbation  and  Emissions ;  Chapter  8,  Treat- 
ment of  Impotency ;  Chapter  IX,  Race  Suicide ;  Chapter  10,  Ster- 
ility; Chapter  11,  Treatment  of  Sterility;  Chapter  12,  Artificial 


190     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Impregnation;  Chapter  13,  Therapeutics.  The  work  is  by  no 
means  exhaustive  but  it  contains  much  of  interest  and  instruc- 
tion for  the  general  practitioner. 


Handbook  of  Anatomy,  Being  a  Complete  Compend  of  Anatomy,  includ- 
ing the  Anatomy  of  the  Viscera,  a  Chapter  on  Dental  Anatomy,  Numer- 
ous Tables,  and  Incorporating  the  newer  Nomenclature  Adopted  by  the 
German  Anatomical  Society,  Generally  Designated  the  Basle  Nomen- 
OrthopcEdic  Surgery,  Philadelphia  Polytechnic ;  Associate  Professor  of 
Orthopaedic  Surgery,  Philadelphia  Polyclinic ;  Associate  Professor  of 
Orthopoedic  Surgery,  University  of  Pennsylvania ;  Orthopoedic  Surgeon 
to  the  Philadelphia  General  Hospital ;  Fellov^^  of  the  College  of  Physi- 
cians, of  Philadelphia ;  Fellow  of  the  Philadelphia  Academy  of  Surgery ; 
Fellow  of  the  American  Orthopoedic  Association ;  Member  of  the  Amer- 
ican Medical  Association,  etc.  Fifth  Edition,  Revised  and  Enlarged. 
With  154  Engravings,  some  in  Colors.  Philadelphia.  F.  A.  Davis  Co., 
Publishers.     English  Depot.     Stanley  Phillips,  London.     1917. 

We  acknowledge  the  receipt  of  the  5th  edition  of  this  popular 
handbook  of  anatomy,  revised  and  enlarged.  The  work  is  fully 
illustrated,  the  text  is  succinct  and  clean  and  the  arrangement 
systematic  and  logical.  The  condensed  arrangement  renders  its 
size  particularly  acceptable  to  students  so  that  it  should  prove  of 
exceptional  convenience  as  a  handbook  in  the  studies  of  the  dis- 
secting room.  In  order  to  make  the  work  thoroughly  accurate 
and  modern,  it  was  deemed  advisable  to  incorporate  throughout 
the  volume  the  Basle  nomenclature  or  B.N. A.  as  formulated  and 
adopted  by  the  German  Anatomical  Society.  A  special  chapter 
devoted  to  dental  anatomy,  properly  illustrated,  has  been  added, 
making  it  especially  adaptable  to  the  needs  of  dental  students. 
We  heartily  recommend  the  work  as  an  exceptionally  useful  text- 
book for  students. 


PUBLISHERS'  DEPARTMENT  191 


Publtslj^r'a  i^partm^nt 


A  Sedative  of  Superior  Worth. 


The  reason  PASADYXE  (Daniel)  occupies  such  a  high  place  in  the 
therapeutic  armamentarium  of  many  hundreds  of  physicians  is  because  of 
its  potency  as  a  sedative  agent  and  its  freedom  from  untoward  effects. 
Thus,  PASADYNE  (Daniel)  may  be  pushed  vigorously  and  no  depres- 
sion or  other  disagreeable  after-effect  experienced.  PASADYNE  (Daniel) 
is  merely  a  pure  concentrated  tincture  of  passiflora  incarnata — a  safe  and 
satisfactory  sedative. 

Sample  bottle  may  be  had  by  addressing  the  laboratory  of  John  B.  Daniel, 
Inc.,  Atlanta,  Ga. 


Speaking  of  Opiates. 


The  objections  to  the  employment  of  opium  and  morphine  are  two-fold. 
Following  their  use  there  usually  is  depression  or  partial  suppression  of 
normal  functions,  and  if  the  drug  is  given  hypodermically  or  in  such  fash- 
ion that  its  character  is  easily  recognized  by  the  patient  the  formation  of 
a  habit  comes  into  the  realm  of  the  possible.  To  a  large  degree  PAPINE 
(Battle)  obviates  these  disadvantages.  In  the  first  place  PAPINE  (Bat- 
tle) is  prepared  with  the  greatest  care  and  from  the  purest  drugs.  The 
name  is  not  indicative  to  the  lay  mind  of  its  purposes  and  thus  the  patient 
is  protected  from  falling  into  a  habit.  All  in  all,  PAPINE  (Battle)  is 
the  opiate  of  first  choice. 


The  Continued  Use  of  Cod  Liver  Oiu 


A  marked  disadvantage  attaching  to  the  long  continued  use  of  the  ordi- 
nary emulsion  of  cod  liver  oil  is  the  gastro-intestinal  distress  thereby 
occasioned.  In  many  instances  this  distress  makes  it  obligatory  to  dis- 
continue the  oil's  use. 

It  was  to  obviate  this  bad  feature  of  cod  liver  oil  administration  that 
Cord.  Ext.  01.  Morrhuse  Comp.  (Hagee)  was  perfected,  and  how  well  it 
has  met  the  purpose  for  which  it  was  intended  is  best  shown  by  its  wide 
popularity  among  the  profession. 

Cord.  Ext.  01.  Morrhuae  Comp.  (Hagee)  offers  every  advantage  of  the 
plain  cod  liver  oil,  and  owing  to  its  palatability  and  easy  assimilation  it 
may  be  used  indefinitely  without  causing  gastro-intestinal  disturbances. 


The  salicylates  have  long  been  regarded  by  the  profession  as  a  potent 
anti-rheumatics,  whose  efficacy  is  unapproached  by  any  other  known  med- 
icine in  the  treatment  of  neuralgia,  rheumatism,  sciatica  and  other  neu- 


192     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

rotic  lesions.  Tongaline,  from  the  character  of  its  ingredients,  is  bound 
to  possess  special  alterative  and  eliminative  action,  with  positive  affinity 
for  the  excretory  system  of  glands,  necessarily  producing  a  thorough  elimi- 
nation of  the  toxic  and  morbitic  products  of  the  system  through  the  va- 
rious emunctories.  For  rheumatism  and  gout ;  sciatica  and  lumbago,  it  is 
a  remedy  par  excellence,  its  action  being  absolutely  invaluable.  In  these 
diseases  it  thoroughly  eliminates  the  toxaemia,  which,  under  other  treat- 
ments seems  ever  present,  hindering  convalescence  and  producing  relapses. 
Tongaline  here  acts  as  an  efficient  alterative  and  eliminative,  removing 
causes  and  effecting  resolution." 


Every  Claim  Abundantly  Substantiated. 


The  place  Gray's  Glycerine  Tonic  Comp.  has  held  in  practical  thera- 
peutics during  the  last  twenty-hve  years  points  in  no  uncertain  way  to 
the  results  it  has  accomplished  in  the  hands  of  competent  physicians,  men 
who  are  abundantly  able  to  judge  of  its  usefulness  as  a  simple,  re- 
liable and  remarkably  effective  remedy  in  the  treatment  of  all  phases  of 
debility,  inanition  and  malnutrition  of  functional  origin. 

During  all  this  time  no  claims  have  ever  been  made  concerning  the  effi- 
cacy of  Gray's  Glycerine  Tonic  Comp.  that  have  not  been  founded  on — 
and  abundantly  substantiated  by — the  unsolicited  statements  of  competent 
medical  observers.  The  present  widespread  use  of  Gray's  Glycerine  Tonic 
Comp.  by  thousands  of  skilled,  conservative  physicians  all  over  the  country 
is  due  entirely  to  their  denifite  knowledge  of  its  action  and  effects.  In 
other  words,  its  use  has  been  based  on  experience  and  judgment,  and  it  is 
on  these  grounds — and  these  alone — that  the  manufacturers  of  Gray's 
Glycerine  Tonic  Comp.  expect  medical  men  to  use  this  product. 

Results — and  results  alone — are  the  criterion  of  the  worth  of  a  remedy, 
and  it  is  on  the  results  that  it  has  achieved  in  the  hands  of  the  earnest 
painstaking  physicians  of  the  country  that  the  success  of  Gray's  Glycerine 
Tonic  Comp.  has  been  built. 

Have  you  some  patient  convalescing  from  some  acute  disease?  Why 
not  try  Gray's?  Send  for  samples  to  the  Purdue  Frederick  Co.,  135  Chris- 
topher St.,  New  York. 


In  Pruritus. 


Even  in  severe  forms  of  genital,  anal,  diabetic,  eczematous  itching,  K-Y 
Lubricating  Jelly,  in  a  great  majority  of  cases,  will  bring  relief,  or  at  least 
grateful  alleviation. 

To  anoint  the  skin  in  these  conditions,  K-Y  Lubricating  Jelly  is  not  only 
effective,  but  convenient  and  economical,  since  it  can  be  used  without  soil- 
ing the  bed  clothes  or  the  patient's  linen.  If  the  part  is  washed  before 
each  application  the  best  results  are  obtained. 


NASHVILLE  JOURNAL 

OF  

MEDICINE  AND    SURGERY 


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


Vol.  CXI.  JULY,  1917.  No.  7 


Original  QlnmmumrattnnB 


ENTEROSTOMY;  A  PERFECTED  TECHXIC* 


John  Wesley  Long,  M.D.,  Greensboro,  N.  C. 


Enterostomy  should  never  be  done  as  a  matter  of  choice.  It 
is  not  an  operation  of  election  if  it  be  possible  to  successfully 
use  any  other  method.  On  the  other  hand  it  is  a  life-saving  meas- 
ure and  has  rescued  many  a  patient  from  an  untimely  grave. 

The  writer  would  not  advocate  a  wider  application  of  enter- 
ostomy, rather  does  he  believe  in  a  very  restricted  use  of  this 
invaluable  operation.  Every  surgeon  must,  as  a  matter  of  course, 
be  his  own  judge  as  to  the  indications  for  doing  enterostomy,  but 
it  is  surprising  even  to  those  who  have  given  the  subject  careful 
thought  that  varying  conditions  may  be  relieved  by  the  procedure. 
Many  cases  of  intestinal  obstruction  are  entirely  cured  by  simply 
an  enterostomy. 

The  indications  may  be  roughly  grouped  as  follows :  First,  to 
relieve  temporarily  patients  suffering  with  intestinal  obstruction, 
as  from  carcinoma  of  the  colon;  second,  to  safeguard  an  opera- 
tion done  at  the  same  sitting,  as  resection  of  the  bowel ;  third,  to 


*Read  before  the  Southern  Surgical  and  Gynecological  Association, 
White  Sulphur  Springs,  W.  Va.,  December  12,  1916. 


194     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

overcome  the  evil  results  of  a  previous  operation,  for  instance, 
obstruction  following  abdominal  section ;  and  fourth,  to  establish 
an  opening  thiough  which  to  feed  a  patient,  as  a  jejunostomy 
done  for  inoperable  conditions  of  the  stomach. 

An  operation  capable  of  such  a  high  degree  of  efficiency  and 
for  so  many  conditions  deserves  to  be  standardized.  That  it  is 
an  approved  operation  is  evidenced  by  the  testimony  of  many 
surgeons,  but  so  far  no  one  has  established  a  generally  accepted 
technic  for  doing  it. 

For  the  purpose  of  illustrating  the  technic  herein  ofifered  we 
may  describe  a  case  of  intestinal  obstruction  following  abdominal 
section.  By  the  second,  third  or  fourth  day  the  bowels  have  not 
been  moved  nor  has  flatus  passed.  There  are  increasing  tympany, 
muscular  rigidity  and  abdominal  tenderness.  Acute  dilatation 
of  the  stomach  develops,  with  excessive  thirst  and  frequent  vomit- 
ing of  stomach  and  duodenal  contents.  The  stomach  tube  gives 
only  temporary  relief.  The  patient  is  restless,  anxious  and  evi- 
dently losing  ground.  Auscultation  of  the  abdomen  reveals  in- 
testinal metallic  gurgling  sounds  due  to  paroxysmal  waves  of 
peristalsis  occurring  at  frequent  intervals.  The  peristalsis  forces 
the  liquid  and  gaseous  contents  of  the  bowel  to  the  point  of  ob- 
struction and  produces  much  pain.  Uranalysis  shows  albumen, 
casts  and  indican  in  increasing  quantities. 

No  wise  surgeon  gives  purgatives  under  such  circumstances. 
Enemas  of  every  kind  have  been  tried  and  failed.  The  patient's 
condition  is  getting  desperate,  something  must  be  done  and  that 
quickly.  Often  by  this  time  not  only  the  patient  but  the  family 
as  well  have  become  demoralized.  The  thought  of  another  op- 
eration only  adds  to  the  confusion.  It  is  in  cases  of  this  kind 
that  enterostomy  ofifers  the  greatest  relief. 

If  circumstances  will  permit  the  patient  should  be  gently  re- 
moved to  the  operating  room  where  any  measure  can  more  con- 
veniently be  carried  out.  However,  an  enterostomy  can  be  done 
without  moving  the  patient  from  the  bed.  With  the  judicious 
use  of  a  local  anesthetic  and  the  persuasive  words  of  the  tactful 
surgeon  the  entire  operation  may  be  carried  out  without  produc- 
ing either  pain  or  fright. 


ORIGINAL  COMMUNICATIONS  19S 

Under  the  plea  of  "dressing  the  wound"  a  few  stitches  are  re- 
moved and  the  edges  of  the  incision  gently  separated.  When  the 
peritoneum  is  opened  one  should  not  search  for  the  point  of  ob- 
struction, unless  it  be  easily  reached,  but  content  himself  by  deal- 
ing with  the  first  distended  coil  of  intestine  that  presents  itself. 
The  emphasis  is  upon  distended,  since  it  is  worse  than  useless  to 
puncture  the  bowel  below  the  obstruction.  When  the  obstruction 
is  purely  mechanical  and  no  sepsis  is  present  more  freedom  is 
allowable.  Without  disturbing  the  parts  unduly  a  purse-string 
suture,  preferably  of  chromic  gut,  is  placed  into  the  bowel  wall. 
The  needle  should  be  introduced  rather  deeply.  An  area  a  good 
half  inch  in  diameter  is  included.  By  catching  the  suture  at  two 
equi-distant  points  with  forceps  and  the  untied  ends  between  the 
fingers,  sufficient  tension  can  be  maintained  to  serve  the  double 
purpose  of  steadying  the  parts  and  reduce  the  soiling  of  the  field 
to  a  minimum. 

While  the  suture  is  being  held  the  pencil  point  of  a  thermo- 
cautery is  made  to  slowly  bum  a  hole  into  the  intestine.  The 
cautery  is  preferable  to  the  knife  or  scissors  for  several  good  rea- 
sons ;  first,  a  burnt  wound  does  not  bleed,  while  a  stab  wound  into 
the  intestine  occasionally  severs  a  small  vessel  which  requires 
ligating;  second,  a  perforation  made  by  burning  tends  to  con- 
tract rather  than  to  get  larger,  which  is  an  important  considera- 
tion when  dealing  with  an  intestinal  fistula ;  third,  the  heat  seals 
the  various  coats  of  the  intestine  together  so  that  the  edges  do 
not  separate  or  retract ;  fourth,  there  is  a  notable  absence  of  ever- 
sion  of  the  mucosa,  which  is  seen  in  stab  and  pistol  shot  wounds 
of  the  intestines. 

Before  the  perforation  is  made  the  enterostomy  tube  should  be 
prepared  and  near  at  hand  so  that  as  the  cautery  point  is  with- 
drawn the  tube  may  be  immediately  introduced  and  thus  avoid 
the  escape  of  intestinal  contents.  The  tube  is  preferably  one  of 
fairly  soft  rubber  that  will  not  collapse.  It  should  be  smooth 
and  without  enlargement  of  any  kind.  A  tube  twice  the  size  of 
the  opening  can  be  easily  introduced,  since  the  bowel  wall  is  suf- 
ficiently elastic.     The  disproportion  between  the  size  of  the  tube 


196     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

and  the  fistula  causes  the  rim  to  hug  the  tube  closely,  which  pre- 
vents leaking. 

The  forceps  are  now  removed  from  the  suture  and  the  ends 
tied.  With  a  little  care  the  inversion  of  the  edge  of  the  perfora- 
tion is  easily  effected.  If  the  condition  of  the  intestinal  wall  will 
permit,  a  second  purse-string  suture  adds  to  the  security  and  in- 
creases the  inversion,  which  favors  the  subsequent  healing  of  the 
fistula  by  bringing  a  wider  margin  of  serosa  to  serosa. 

Whenever  it  is  possible  to  do  so,  the  omentum  should  be  drawn 
about  the  tube  and,  if  need  be,  stitched  in  place  by  one  or  two  fine 
plain  cat-gut  sutures.  A  splendid  plan  is  to  puncture  the  omen- 
tum and  pass  the  distal  end  of  the  tube  through  it.  Utilization 
of  the  omentum  with  which  to  safeguard  the  intestinal  opening, 
both  before  and  after  the  tube  has  been  withdrawn,  can  not  be 
too  strongly  emphasized. 

Formerly  the  writer  stitched  the  tubing  to  the  intestine  in  order 
to  secure  it  in  place ;  but  this  is  a  mistake,  since  the  suture  from 
tube  to  gut  is  liable  to  cut  out  of  the  intestine  and  increase  the 
size  of  the  opening.  Besides,  on  subsequently  removing  the  tube 
the  anchor  suture  disturbs  the  inversion,  greatly  interfering  with 
the  healing.  The  tube  is  best  secured  by  narrow  strips  of  adhe- 
sive plaster  to  the  skin. 

Unless  the  abdominal  cavity  be  already  shut  off  from  the  field 
of  operation  by  adhesions  the  open  portion  of  the  wound  should 
be  filled  with  fluffy  gauze  which  will  protect  the  peritoneum  and 
promote  the  formation  of  adhesions. 

When  the  perforation  has  been  done  with  the  cautery,  the  e(^ige 
properly  inverted,  and  the  parts  surrounded  by  omentum,  the 
fistula  usually  heals  of  itself  very  promptly.  The  writer  has  had 
fistulae  that  did  not  leak  a  drop,  either  before  or  following  the 
removal  of  the  tube.  While  there  is  no  operation  more  service- 
able than  an  enterostomy  when  indicated  there  can  be  nothing 
more  annoying  than  a  fecal  fistula  that  will  not  heal.  The  tech- 
nic  herein  described  reaps  the  benefits  of  the  one  and  avoids  in  a 
large  percentage  of  cases  the  evil  effects  of  the  other. 

This  method  of  doing  enterostomy  can  be  safely  accepted  as 
the  standard.     Also  it  may  be  said  that  like  the  singing  of  the 


ORIGINAL  COMMUNICATIONS  197 

Southern  mocking-bird,  one  of  its  chief  beauties  is  the  variations 
to  which  its  technic  is  susceptible,  and  that,  too,  without  departing 
from  the  principles  involved  in  its  standardization. 

For  instance,  the  use  of  the  appendix  through  which  to  insert 
a  catheter  for  drainage  is  only  a  refined  method  of  doing  enteros- 
tomy. Under  certain  circumstances,  it  is  not  necessary  to  use  a 
purse-string  or  indeed  a  suture  of  any  kind.  Occasionally,  after 
the  distended  bowel  is  emptied  its  walls  are  so  flacid  as  to  allow 
of  an  inch  or  two  of  the  drainage  tube  being  covered  by  suturing 
the  bowel  over  it  similar  to  a  Witzel  gastrostomy.  This,  how- 
ever, is  not  often  advisable,  especially  if  the  omentum  can  be 
made  to  surround  the  fistula.  In  some  cases  the  omentum  can  not 
be  utilized.  Securing  the  fistulus  area  to  the  parietal  peritoneum 
by  a  continuous  suture  after  the  manner  of  Kocher  is  not  advis- 
able unless  a  permanent  fistula  is  desired.  If  it  is  thought  expe- 
dient, the  bowel  may  be  anchored  to  the  peritoneum  with  two  to 
four  interrupted  sutures.  Should  it  not  be  practical  to  open  the 
abdomen  through  the  former  incision  it  is  easy  enough  to  make 
an  independent  incision  under  local  anesthesia.  Other  variations 
might  be  mentioned,  but  suffice  it  to  say  that  a  standardized  tech- 
nic once  understood  and  approved  can  be  easily  adapted  to  meet 
the  conditions  found. 


198     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


Btitttth  Arttrbfi 


COLONEL  ROOSEVELT'S  SPEECH  BEFORE  THE 
AMERICAN  AIEDICAL  ASSOCIATION* 


In  speaking  to  the  doctors,  I  address  a  body  of  men  whose  pro- 
fession is  honorably  distinguished  because  in  practical  fashion  it 
sets  service  as  the  ideal  before  those  who  follow  it.  Of  course  a 
doctor,  like  everyone  else,  must  earn  his  own  livelihood  and  make 
enough  money  to  support  his  own  wife  and  children,  or  he  will  be 
only  a  drag  on  the  community ;  and  equally  of  course  in  your  pro- 
fession, as  in  every  other  profession,  there  are  some  sordid  crea- 
tures who  think  only  of  making  money.  But  these  men  are  the 
exceptions,  and  there  is  in  your  profession  a  strong  public  opinion 
which  scorns  such  a  sordid  perversion  of  your  great  and  noble  art. 
You  preach  and  practice  the  doctrine  of  service;  of  service  ren- 
dered primarily  for  itself  and  only  secondarily  for  the  money 
reward. 

In  the  present  great  national  crisis  of  the  world  war,  it  is  pre- 
cisely this  doctrine  of  service  upon  which  we  need  to  lay  most 
stress.  Of  course  service  normally  means  self-sacrifice.  But  I 
do  not  think  that  you  ought  to  let  your  minds  dwell  very  much 
on  the  sacrifice.  The  man  who  does  not  heartily  do  his  full  duty 
by  the  nation  in  this  crisis  is  not  fit  to  be  a  citizen.  He  does  well, 
but  not  extraordinarily  well,  if  he  makes  whatever  sacrifice  is  nec- 
essary. But  if  he  does  not  make  such  sacrifice  he  shows  himself 
to  be  an  abject  creature,  who  should  be  hunted  out  of  the  society 
of  self-respecting  freemen.  What  we  need  to  hold  ever  before 
our  eyes  is  not  the  incidental  sacrifice  but  the  high  honor  and 
privilege  of  being  permitted  to  render  the  service.  Every  young 
man  of  the  right  temper  will  eagerly  long  for  the  chance  to  render 
such  service  and  will  count  himself  thrice  fortunate  if    he  wins 


*Through  the  courtesy  of  Colonel  Roosevelt  we  are  enabled  to  pub- 
lish this  eloquent  address,  which  was  delivered  at  the  Hippodrome, 
June  7,  1917,  to  a  large  audience  of  physicians. 


SELECTED  ARTICLES  199 

the  great  prize  of  securing  the  chance  to  render  it,  no  matter  what 
price  he  may  pay  in  danger  and  hardship.  This  is  especially  true 
of  voung  doctors,  for  surgeons  are  sorely  needed  for  our  Allies 
and  for  ourselves.  England,  France,  Italy,  and  perhaps  above 
all,  Russia,  Servia,  Armenia,  and  Syria,  need  them.  As  for 
our  own  men,  if  we  do  not  effectively  exert  every  effort  to  pre- 
vent sickness  among  and  secure  camp  hygiene  for  our  soldiers, 
we  shall  show  ourselves  guilty  of  the  gravest  moral  dereliction. 
Every  young  doctor  should  volunteer  his  services ;  no  man  has  a 
right  to  hold  back  unless  he  has  a  young  family  with  claims  so 
urgent  that  they  can  not  be  disregarded. 

Some  well-meaning  men  talk  as  if  their  duty  would  be  fully 
performed  if  they  served  when  drafted.  This  is  a  great  error. 
Service  under  the  draft  merely  represents  the  minimum  duty 
which  will  be  accepted  by  the  State.  If  it  lies  within  your  power 
you  should  strive  to  render  far  more  than  the  minimum  service. 
Many  good  men  of  no  special  aptitude  for  other  than  line  work 
will  not  be  able  to  get  the  chance  to  render  service  until  and  un- 
less they  are  drafted.  Therefore  the  drafted  man  who  does  his 
duty  stands  on  a  full  level  of  honor  with  the  man  who  volunteers 
to  do  duty.  But  the  man  who  is  not  drafted  does  not  stand  on  a 
level  with  his  drafted  brother  unless  he  eagerly  and  persistently 
seeks  the  opportunity  to  volunteer  wherever  he  can  do  useful 
service.  If  he  is  denied  this  opportunity  through  no  fault  of  his 
own,  then  he  is  free  from  all  blame;  although  if  he  is  of  the 
right  type  he  will  bitterly  regret  that  he  has  not  been  allowed  to 
render  the  service.  But  he  must  be  in  good  faith  and  earnestly 
seek  the  opportunity.  The  young  doctor  or  surgeon,  and  the 
young  man  who  is  fitted  to  render  service  of  any  kind  under  the 
doctors  in  the  Medical  Corps,  are  badly  needed  at  this  moment. 
They  are  needed  now;  this  week;  today.  Therefore  let  every 
young  doctor,  every  young  man  fit  to  render  aid  under  a  doctor, 
come  forward  at  once  and  volunteer  his  services. 

This  work  I  ask  you  to  do  is  of  imperative  importance,  and  the 
need  is  instant.  Meet  that  need  now.  Do  not  wait.  Speed  is  of 
the  first  consequence.  All  of  you  here,  as  soon  as  you  get  back 
to  your  home  towns,  proceed  to  arrange  the  hospital  assignments, 


200     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

and  everything  of  that  kind,  so  that  the  young  fellow  just  out  of 
college  or  the  medical  school  will  be  free  to  volunteer  for  imme- 
diate service  in  our  army.  Let  the  older  men  who  because  of  age, 
or  of  other  disabilities,  or  for  other  good  reason,  can  not  get  into 
the  army,  arrange  to  do  the  work  the  young  men  usually  do,  and 
leave  the  latter  free  to  volunteer  for  service  abroad.  This  will 
mean  that  the  men  of  each  class,  those  able  to  go  and  those  not 
able  to  go,  will  be  doing  their  full  duty.    Do  it  now ! 

We  are  in  the  great  war  for  the  sake  both  of  our  national  honor 
and  vital  national  interest,  and  for  the  sake  of  humanity  and  civ- 
ilization throughout  the  world.  For  two  years  before  we  most 
reluctantly  went  to  war,  Germany  had  been  engaged  in  a  steady 
and  relentless  campaign  of  murder  against  American  women  and 
children  and  unarmed  men.  Germany  has  struck  blows  at  inter- 
national right  and  justice  which  means  that  unless  she  is  signally 
punished  the  whole  movement  for  international  fair  dealing  and 
brotherhood  will  have  been  put  back  for  centuries.  To  the  con- 
quered countries  she  has  behaved  with  a  systematic  and  appalling 
brutality  which  is  literally  unparalleled  among  civilized  nations 
since  the  close  of  the  hideous  religious  wars  of  the  seventeenth 
century.  I  wish  that  every  American  would  read  Arthur  Glea- 
son's  just  published  book,  "Our  Part  in  the  Great  War" ;  for  no 
American  who  reads  it  can  fail  to  feel  his  blood  boil  with  horror 
and  anger  over  the  fearful  cruelties  it  recounts,  and  the  shameful 
folly  this  country  showed  in  not  instantly  taking  action  to  rebuke 
those  cruelties  and  in  refusing  even  to  prepare  to  defend  itself. 
No  American  who  reads  it,  if  he  has  a  spark  of  manhood  and  of 
the  old  American  spirit  in  his  soul,  can  fail  to  feel  his  heart  harden 
with  the  resolute  purpose  (inasmuch  as  at  last,  thank  Heaven, 
we  have  dared  to  fight  for  the  right)  to  do  his  part  in  seeing  that 
this  nation  remains  steadfast  in  the  war  until  it  is  crowned  by 
complete  and  overwhelming  victory ;  and  let  this  man  feel  that 
his  children  will  turn  from  him  in  shame  unless  he  does  all  that 
in  him  lies  to  aid  in  bringing  this  victory. — International  Journal 
of  Surgery. 


EXTRACTS  FROM  JOURNALS  201 


CxtrartB  from  ^amt  nnh  Jffnr^ tgn  SnurttalB 


SURGICAL 


Results  of  Operation  for  Breast  Tumors. 


Pilcher's  paper  is  summarized  as  follows :  In  the  early  period 
in  the  development  of  every  cancer  of  the  breast  it  is  absolutely 
curable.  If  this  fact  were  brought  home  to  every  woman,  there 
would  not  longer  be  any-deaths  from  cancer  of  the  breast.  Even 
a  large  and  long  active  surgical  experience  does  not  qualify  any 
man  to  say  positively  in  many  cases  of  chronic  cystic  mastitis 
(secondary  cytoplasia )  whether  there  is  a  malignant  element 
present  or  not.  Recognizing  the  frequency  with  which  the  supra- 
clavicular glands  are  invaded  in  tumors  in  the  upper  quadrants  of 
the  breast,  it  is  urged  that  every  advanced  case  should  have  the 
benefit  not  only  of  axillary  gland  dissection,  but  also  removal  of 
the  supraclavicular  glands  as  a  part  of  the  primary  operation. 
Cases  of  recurrence,  even  in  which  the  opposite  axilla  or  other 
breast  becomes  involved,  are  not  necessarily  fatal. — The  Journal 
of  the  American  Medical  Association. 


Spontaneous  Rupture  of  the  Stomach. 


This  accident,  at  least  when  it  occurs  in  a  healthy  stomach 
without  trauma,  must  be  extremely  rare.  Steinmann,  the  well 
known  Swiss  surgeon  who  has  just  reported  a  case  in  the  Corre- 
spondens-Blatt  fur  Schzvei::er  Aerzte  for  March  10,  has  been 
unable  to  find  a  duplicate  in  literature.  The  victim  was  a  young 
girl  aged  17  years  who  at  her  noon  meal  ate  sour  krout  and  later 
suffered  from  gastralgia,  vomiting  and  diarrhea.  There  was 
progressive  meteorism  and  at  8.15  p.  m.  the  patient  felt  a  severe 
pain  and  told  her  mother  that  something  had  burst  within  her. 
She  was  taken  at  once  to  the  hospital,  where  laparotomy  was  per- 


202     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

formed  after  a  diagnosis  of  perforative  peritonitis.  Tlie  peri- 
toneal exudate  had  an  acid  odor  and  much  of  the  sourkrout  was 
found  in  abundance  as  far  down  as  the  lesser  pelvis.  The  in- 
flated and  partly  adherent  colon  was  lifted  up  and  a  rupture  found 
on  the  posterior  wall  of  the  stomach  which  measured  7  cm.  in 
length.  Not  the  slightest  trace  of  a  previous  ulcer  was  found. 
The  rupture  was  sutured,  the  abdominal  cavity  flushed  with  sa- 
line and  a  thick  drainage  tube  was  inserted  between  the  lesser 
pelvis  and  lower  angle  of  the  wound.  Foul  pus  escaped  through 
the  tube  but  this  condition  was  soon  overcome  by  the  author's 
continuous  air  douche.  The  patient  made  a  complete  recovery. 
It  was  assumed  that  rupture  occurred  as  a  result  of  closure  of 
the  cardia  by  the  sour  krout.  The  gas  generated  in  the  stomach, 
unable  to  escape,  eventually  caused  the  rent  in  the  wall  of  the 
viscus. — Medical  Record. 


Skin  Grafting. 


In  a  well  illustrated  article,  in  the  International  Clinics  for 
June,  Shipley  describes  the  excellent  results  he  has  obtained  in 
the  treatment  of  chronic  leg  ulcers  by  the  use  of  skin  grafts.  He 
employed  the  method  described  by  John  Staige  Davis  in  the  Jour- 
nal of  the  American  Medical  Association,  September  19,  1914. 

Shipley  reports  eight  cases  of  the  obstinate  type  of  leg  ulcer 
in  which  complete  success  was  obtained. 

He  recommends  this  method  for  the  following: 

First — The  ease  and  the  simplicity  of  the  procedure. 

Second — Its  uniform  success  if  the  proper  precautions  are 
taken  in  the  preparation  of  the  surfaces  and  the  application  of 
the  grafts. 

Third — The  robust  surface  that  is  formed  by  the  graft. 

Fourth — The  fact  that  the  operation  can  be  done  without  a 
general  anesthetic. 

Fifth — The  very  rapid  and  remarkable  filling  up  of  the  base  of 
the  ulcer  to  the  level  of  the  surrounding  tissues. 

The  method  is  not  available  on  an  exposed  surface  like  the 
face,  unless  the  grafts  are  closely  placed,  otherwise  the  resulting 
surface  has  a  spotted  appearance. — Arthur  M.  Shipley,  M.D. 


SELECTED  ARTICLES  203 

Blood  Change  in  Gas  Poisoning. 


The  blood  in  forty-four  cases  of  gas  poisoning  was  studied  by 
IMiller.  He  now  says  that  in  cases  of  gas  poisoning  in  which 
symptoms  persist,  there  is  an  increase  in  the  number  of  lympho- 
cytes, relative  and  absolute,  in  the  circulating  blood.  In  slight 
cases  this  may  not  be  beyond  the  normal  limits  or  in  excess  of 
what  may  be  met  with  from  other  causes.  In  any  marked  case, 
however,  the  change  is  sufficiently  striking  to  be  of  some  im- 
portance in  cases  in  which  the  medical  officer  is  in  doubt  as  to  the 
reliance  to  be  placed  on  the  statements  of  men  complaining  of 
having  been  gassed.  TJie  blood  change  is  elicited  by  a  differential 
count  of  the  leukocytes,  and  if  the  percentage  of  lymphocytes  ap- 
proaches that  of  the  polymorphonuclear  leukocytes,  it  indicates 
that  the  patient  is  still  suft'ering  from  the  effects  of  the  gassing; 
that  is,  provided  there  is  no  other  complicating  diseases  present 
which  might  produce  a  similar  change.  The  cell  which  is  in- 
creased is  the  ordinary  small  lymphocyte  of  the  blood.  There 
may  be  in  some  cases  a  diminution  in  the  number  of  polymor- 
phonuclear leukocytes  which  will,  of  course,  accentuate  the  sign, 
but  the  increase  of  lymphocytes  is  an  absolute  one.  Moreover,  it 
appears  in  cases  with  a  high  leukocyte  count.  The  change  is  one 
which  develops  early,  probably  within  a  month  of  the  gassing,  and 
continues  for  a  long  time ;  in  cases  with  persistent  symptoms,  for 
at  least  eighteen  months.  The  change  appears  to  be  independent 
of  the  kind  of  gas,  and  it  is  shown  by  patients  exhibiting  many 
varieties  of  symptoms.  It  is  not  clear  what  the  change  is  due  to, 
but  Miller  suggests  that  it  is  probable  that  chronic  inflammatory 
change  in  respiratory  and  gastric  mucous  membranes  is  at  least 
a  factor. — Journal  of  the  Am.  Med.  Asso. 


Immobilization  of  Tuberculous  Lung  by  Extraction 
OF  Intercostal  Nerves. 


The  Ugeskrift  for  Lacger  gives  a  summary,  p.  383,  of  an  il- 
lustrated article  by  Warstate  in  the  Deutsche  Zeitschrift  fiir  Chir- 
urgie  describing  his   success  in  excluding  the  tuberculous   lung 


204     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

from  participation  in  respiration  by  extracting  a  stretch  of  eacii 
intercostal  nerve  on  that  side.  Attempts  have  been  made  to  ar- 
rest the  functioning  of  half  of  the  diaphragm  by  severing  the 
phrenic  nerve.  But  the  effect  of  this  is  restricted  to  the  lower 
portion  of  the  lung,  while  tuberculous  processes  usually  are  lo- 
cated in  the  upper  portion.  The  upper  portion  can  be  immob- 
ilized by  paralyzing  the  thoracic  muscles  of  respiration.  He  ex- 
poses the  intercostal  nerves  from  the  second  to  the  eleventh,  in- 
clusive, his  incision  being  along  the  margin  of  the  erector  spinse. 
He  cuts  each  nerve  distal  from  the  dorsal  root,  and  then  twists 
the  distal  end  of  the  nerve  out  with  forceps.  He  applied  this 
operation  to  sixteen  rabbits  and  one  dog,  and  when  killed  weeks 
or  months  later  the  lung  was  found  materially  reduced  in  size 
and  of  solid  consistency.  The  abdominal  muscles  did  not  seem 
to  feel  any  effect  from  the  operation,  either  in  the  animals  or  in 
the  two  clinical  cases  in  which  he  has  applied  it.  In  his  first  pa- 
tient that  half  of  the  thorax  did  not  participate  at  all  in  inspira- 
tion, and  in  three  months  was  much  flatter.  The  patient's  condi- 
tion had  improved  notably  by  the  end  of  six  months,  the  tubercu- 
lous process  having  been  unmistakably  arrested.  There  was  no 
cavity  in  the  second  patient,  and  the  whole  set  of  symptoms  dis- 
appeared in  the  course  of  a  few  months. — The  Journal  of  the 
American  Medical  Associatiojt. 


Enucleation  of  Eye  With  Implantation  of 
Patient's  Fat  Into  the  Cavity. 


John  M.  Wheeler,  M.D.,  American  Journal  of  Surgery.  The 
author  recommends  that  in  enucleation  all  the  tissues  outside  the 
sclera  be  saved.  The  muscles  are  clamped  at  their  insertions  be- 
fore cutting.  After  the  globe  is  removed  bleeding  is  stopped  by 
pressure  with  sponges.  A  piece  of  subcutaneous  fat  is  removed 
from  the  inner  aspect  of  the  thigh  and  placed  in  the  orbit,  the 
muscles  being  crossed  and  sutured  over  it.  Tenon's  capsule  is 
then  brought  together  by  a  purse  string  suture,  and  the  conjunc- 
tiva closed  by  fine  silk  interrupted  sutures.     A  shell  can  be  worn 


EXTRACTS  FROM  JOURNALS  205 

three  weeks  after  the  operation.     The  following  advantages  are 
claimed : 

1.  Good  motility  of  stump  and  artificial  eye. 

2.  Thin  shell  can  be  worn,  and  this  is  held  in  good  position  as 
to  proper  prominence  and  proper  tilt  without  having  to  rest  on 
the  lower  lid. 

3.  The  lachrymal  drainage  is  usually  good. 

4.  The  orbital  tissues  are  not  required  to  retain  substances  for- 
eign to  them. 

5.  There  is  no  danger  of  sympathetic  ophthalmia  due  to  the 
presence  of  the  fat,  and  nothing  has  been  introduced  which  can 
be  broken  or  extended. — Pacifiic  Medical  Journal. 


MEDICAL 


J.\UNDiCE  With  an  Enlarged  Liver  in  a  Young  Adult. 
(Primary  Carcinoma  of  the  Gall-Bladder.) 


An  example  of  this  rare  condition  is  reported  in  the  Interna- 
tional Clinics    for  June,  by  AIcGrae. 

The  patient  was  a  young  man,  age  thirty  years,  who  entered 
the  hospital  because  of  illness  dating  back  five  months.  The  trou- 
ble began  with  pain  in  the  right  side,  loss  in  weight.  Jaundice 
appeared  about  three  weeks  after  his  admission  to  the  hospital. 
Physical  examination  showed  prominence  of  the  surface  veins 
of  the  abdomen  and  fulness  in  the  epigastrium  was  due  to  a  firm 
mass  with  a  distinct  edge  which  came  within  1  c.  m.  of  the  navel 
in  the  mid-line.  The  mass  extended  to  the  left  beneath  the  left 
costal  margin  opposite  the  ninth  rib.  To  the  right  it  passed  under 
the  right  costal  margin  and  in  the  nipple  line  is  felt  below  the 
costal  margin  on  deep  inspiration.  The  mass  was  smooth  and  hard 
and  presented  no  irregularities.  The  gall-bladder  was  not  felt. 
As  active  anti-syphilitic  treatment  had  been  tried  before  his  ad- 
mission to  the  hospital  and  the  Wassermann  test  was  negative, 


206     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

syphilis  was  ruled  out.  A  moderate  nucocytosis  was  present  and 
the  red  cells  slightly  reduced  in  number. 

After  considering  the  various  conditions  which  might  account 
for  the  tumor  mass,  loss  of  weight,  jaundice,  etc.,  the  diagnosis 
was  correctly  made  by  exclusion.  The  conditions  considered 
were:  Hypertrophic  biliary  cirrhosis  of  Hanot;  syphilis,  portal 
cirrhosis,  abscess,  cholangitis,  angiocholitis  and  neoplasm.  The 
latter  seemed  the  most  probably  diagnosis.  This  was  confirmed 
by  an  exploratory  operation  and  later  by  autopsy. 

The  majority  of  the  cases  of  primary  carcinoma  of  the  gall- 
bladder are  associated  with  gall  stones,  the  figures  varying  from 
75  to  100  per  cent.  The  case  reported  belongs  to  the  exceptions. 
—Thomas  McGrae,  M.D.,  F.  R.  C.  P. 


Kerosene  Oil  in  Diphtheria. 


Dr.  T.  M.  Clayton  in  the  British  Medical  Journal,  gives  us  an 
account  of  cases  of  extremely  severe  diphtheria,  treated  by  coal 
oil  (Kerosene  oil)  successfully.  These  four  grave  cases  of  laryn- 
geal diphtheria,  ranged  in  children  from  2  to  4  years.  Two  of 
these  were  in  such  a  condition  that  tracheotomy  was  out  of  the 
question.  Kerosene  oil  was  administered  internally  in  doses  of 
20  minims  to  all  four,  thrice  successively  every  4  hours,  then  10 
minim  doses  three  or  four  times  daily  until  normal  breathing  was 
established,  which  occurred  in  all  four  cases  in  48  hours. 

From  the  first  dose  breathing  became  easier,  improving  with 
each  successive  administration  until  it  became  tranquil.  No  un- 
toward action  was  observed. 

No  one  would  ever  think  of  administering  kerosene  internally, 
and  would  at  once  discard  it  for  its  mere  taste,  but  we  are  pleased 
to  learn  from  the  author  that  this  taste  can  be  disguised  by  means 
of  compound  decoction  sarsaparilla.  The  author  is  of  opinion 
that  this  remedy  is  likely  to  be  of  great  value  in  conditions  such  as 
spasmodic  croup,  membranous  croup,  diphtheria  and  in  m.any 
throat  affections. 

Kerosene  oil  is  admittedly  a  strong  antiseptic  and  very  prob- 
ably the  cure  is  due  to  these  antiseptic  qualities,  but  whatever  the 


EXTRACTS  FROM  JOURNALS  207 

reason  may  be,  we  must  give  this  new  method  a  further  trial  and 
research. — The  Practical  Medicine. 


The  Mechanism  of  Intestinal  Stasis  in  Children. 


Dr.  Fenton  B.  Turck  of  New  York  presented  this  paper.  He 
reviewed  his  work,  demonstrating  the  permeabiHty  of  the  intesti- 
nal walls  to  bacteria,  and  pointed  out  that  in  infancy  and  early 
childhood  there  was  no  barrier  to  arrest  the  passage  of  the  in- 
testinal flora  since  antibodies  had  not  yet  been  generated  as  they 
were  not  needed.  As  the  body  developed,  the  tissues  became  less 
porous  to  bacteria.  The  "factors  leading  up  to  intestinal  stasis  in 
childhood  were  much  the  same  as  those  responsible  for  this  con- 
dition in  the  adult  excepting  that  the  infantile  organisms  was 
more  susceptible.  The  various  factors  involved  in  the  produc- 
tion of  stasis  in  children  were  a  hypersensitiveness  which  was 
responsible  for  an  anaphylactic  reaction ;  splanchnic  congestion 
due  to  various  causes,  as  overfeeding,  especially  with  meat  ex- 
tractives and  fatty  acids,  fatigue,  shock,  venous  stasis  and  in- 
creased permeability  of  the  intestinal  wall.  Treatment  must  be 
directed  to  the  various  factors  playing  a  part  in  the  production  of 
these  conditions.  It  consisted,  according  to  the  severity  of  the 
case  and  whether  it  was  acute  or  chronic,  in  colonic  and  gastric 
lavage,  intercolonic  and  intergastric  pneumatic  gymnastics,  de- 
mulcents, diet  with  special  attention  to  the  elimination  of  meat 
extractives  and  fatty  acids,  and  the  administration  of  autogenous 
vaccine  made  according  to  the  method  described  by  the  author 
in  a  paper  read  at  a  joint  meeting  of  pediatric  societies  in  Boston, 
November  4,  1916  (See  Medical  Record,  December  2,  1916,  pp. 
1005  and  \Q06).— Pediatrics. 


Relationship  Betw^een  Diabetes  and  Cancer. 


Albert  Robin,  the  eminent  clinician  of  Paris,  states  that  this 
subject  involves  seven  distinct  problems.  If  a  diabetic  has  to  un- 
dergo an  operation  for  cancer  he  is  likely  to  die  of  coma.  No 
operation  should  be  performed  if  patient  has  acetonuria  or  if  he 


208     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

is  seen  to  have  the  double  cachexia.  No  matter  how  severe  the 
diabetes,  an  incipient  cancer  should  be  removed.  In  cancer  of  the 
breast  in  a  diabetic  removal  of  the  former  will  prolong  life,  pro- 
vided that  in  advance  of  operation  sugar  in  the  urine  is  largely 
diminished.  Diabetes  furnishes  a  preferred  soil  for  cancer;  it 
both  invites  it  and  hastens  its  course  (glycemia  is  increased  as  a 
rule  in  most  cancerous  subjects). — Le  Progres  Medical. 


Chiggers. 


Bassewitz  quotes  a  traveler's  description,  dated  1820,  of  the 
tormenting  itching  caused  by  the  minute  red  insects  known  as 
"micuims"  in  Brazil  and  as  "red  lice,"  "chiggers"  or  "jiggers" 
elsewhere.  Bassewitz  knows  a  man  and  his  mother  who  are  never 
affected  by  the  chiggers ;  both  have  familial  cholemia.  He  has  not 
been  able  to  demonstrate  salivary  glands  in  the  insects  but  is  con- 
fident that  they  secrete  an  irritating  fluid  which  induces  afflux  of 
lymph  wherever  they  implant  their  mouth.  This  the  insect  sucks ; 
no  corpuscles  have  been  found  in  them  after  they  have  been  bit- 
ing a.  person.  He  recommends  benzin  or  an  alcoholic  tincture  of 
Peruvian  balsam  for  local  application.  This  kills  them  at  once 
and  they  can  be  removed  without  leaving  the  head  embedded  in 
the  skin.  A  tincture  of  pyrethrum  is  also  useful  both  for  this  and 
to  ward  them  off.  Mentholated  petrolatum  is  recommended  also. 
It  has  the  additional  advantage  of  soothing  the  intense  pruritus 
which  is  liable  to  last  for  some  time  after  the  insects  are  gone. 
Among  the  household  remedies  much  used  are  rubbing  with  rum 
or  an  alcoholic  maceration  of  tobacco  leaves.  In  dogs  and  other 
animals  the  insects  are  found  mainly  around  the  eyes  and  in  the 
ears.  The  nervous  irritation  from  them  may  induce  actual  mania 
or  fits  in  the  animals.  Chiggers  may  also  cause  havoc  in  the 
poultry  yard,  the  accumulations  of  larvae  under  the  wings  and 
around  the  anus  suggesting  an  eruption  with  scabs.  Bassewitz 
advises  burning  over  the  fields  affected,  as  is  done  to  eradicate 
ticks  in  Rocky  Mountain  districts,  saying  that  this  might  aid  at 
the  same  time  in  eradicating  certain  other  causes  for  cattle  ills. — 
Journal  of  the  American  Medical  Association. 


EXTRACTS  FROM  JOURNALS  209 

OBSTETRICAL 


Myoma  and  Pregnancy. 


Heiino  is  convinced  that  the  defective  involution  of  the  uterus 
in  many  cases  is  due  to  the  presence  of  a  myoma,  possibly  unsus- 
pected. In  one  case  he  discovered  a  myomatous  tumor  on  the 
right  cornu  of  the  uterus  after  delivery,  but  it  had  entirely  disap- 
peared by  the  ninth  day.  The  hypertrophy,  softening  and  atrophy 
of  a  small  or  medium  sized  myoma  during  pregnancy  prevent  its 
interfering  with  delivery.  Operative  intervention  was  required 
in  only  four  myoma  cases'*  at  the  Geneva  maternity  in  a  recent 
eight-year  period.  These  cases  are  described  in  detail.  The 
women  were  all  in  the  thirties,  and  the  disturbances  from  the 
myoma  were  so  severe  that  the  uterus  was  removed  notwithstand- 
ing the  pregnancy  of  two,  four  or  eight  months'  standing.  In 
case  of  doubt  as  to  the  myoma,  Beuttner  rubs  the  uterus  lightly, 
to  induce  it  to  contract.  As  it  contracts,  a  myomatous  tumor  is 
thrown  into  greater  relief,  over  it,  but  if  the  protuberance  is 
caused  merely  by  part  of  the  fetus  presenting,  the  protuberance 
disappears  as  the  uterus  contracts  over  it.  In  case  of  doubt  as 
to  an  existing  pregnancy,  when  operative  intervention  is  decided, 
it  should  be  by  a  laparotomy.  If  the  uterus  is  to  be  removed, 
Heimo  advocates  the  Kelly-Beuttner  technic  but  enucleation  may 
answer  all  the  purposes  in  some  cases.  The  vaginal  route  is  liable 
to  disagreeable  surprises.  Only  about  20  per  cent  of  all  the 
known  myoma  cases  in  his  experiences  were  sterile.  When  a 
myoma  is  discovered  in  a  woman  who  has  been  barren  for  ten  or 
twenty  years,  we  can  not  ascribe  the  sterility  always  to  the  pres- 
ence of  the  myoma.  Hofmeier  even  declares  that  a  myoma  fa- 
vors conception,  not  directly  but  because  it  postpones  the  meno- 
pause. Pinard  says  that  uterine  myomas  develop  as  a  conse- 
quence, not  a  cause  of  sterility.  They  are  the  punishment  for  a 
uterus  that  has  not  served  its  physiologic  function.  Heimo  af- 
firms, on  the  other  hand,  that  we  have  unduly  exaggerated  the 
part  played  and  the  influence  exerted  by  myomas  on  sterility  and 
pregnancy. — The  Journal  of  the  American  Medical  Association. 


210     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Delivery  Through  Shell  Wound, 


Saint,  Goelinger  and  Poire  record  (Jour,  de  med.  et  de  chir. 
prat.,  January  10,  1917)  the  case  of  a  woman  six  months  pregnant 
in  whom  delivery  was  brought  about  by  a  remarkable  accident. 
She  lived  in  a  region  occupied  by  the  British  and  constantly  bom- 
barded, and  was  sitting  at  a  window  when  a  shell  exploded  in  the 
street  and  wounded  her  in  the  lower  abdomen.  When  brought  to 
the  hospital  it  was  found  that  the  belly  was  very  painful  and 
palpation  was  so  difficult  that  it  was  impossible  to  determine  the 
position  of  the  fetus.  An  aperture  of  entry  was  found  a  little 
below  and  to  the  left  of  the  umbilicus,  and  that  of  exit  at  a  dis- 
tance of  nine  centimeters  from  the  left  crural  arch.  On  palpation 
it  was  found  that  the  abdominal  muscles  were  completely  divided 
and  that  only  a  bridge  of  skin  was  left  between  the  two  apertures. 
The  patient  was  bleeding  abundantly  through  the  vagina.  The 
bridge  of  skin  was  cut  through  and  laparotomy  was  performed. 
On  the  fundus  there  was  found  a  wound  of  about  five  centimetres 
through  which  was  seen  the  lumbar  region  of  a  fetus  showing  a 
small  wound.  The  wound  was  enlarged,  when  the  fetus  was  eas- 
ily delivered ;  the  pelvis,  which  was  full  of  meconium  and  am- 
niotic fluid,  was  cleaned,  and  the  operation  was  completed  by 
careful  haemostasis  and  suture  of  the  uterus. 

The  case  ran  a  normal  course  and  the  mother  made  a  rapid  re- 
covery. As  for  the  child,  which  was  left  unattended  to,  as  it  was 
believed  to  be  dead,  it  soon  began  to  cry  and  to  show  itself  very 
much  alive.  It  weighed  950  grams ;  but  as  no  incubator  was 
available  it  died  in  fifteen  hours.  The  British  Medical  Journal, 
December  4,  1915,  stated  that  Dr.  Henrot  had  not  long  before 
sriven  to  the  Paris  Academic  de  Medecine  an  account  of  the  bom- 
bardment  of  the  hospital  at  Rheims.  The  maternity  patients 
were  by  way  of  precaution  moved  to  the  cellars  ;  one  of  the  women 
was  delivered  by  the  action  of  a  shell,  which  tore  open  the  abdo- 
men and  uterus;  the  child  had  simply  to  be  extracted. — Buffalo 
Medical  Journal. 


EDITORIALS  211 


Sbitartal 


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should  be  addressed  to  the  Editor. 


Medical  Men  for  the  Army, 


What  is  the  matter  with  the  medical  profession  of  this  country 
that  its  members  appear  backward  in  responding  to  the  appeal  of 
the  government  to  fill  the  urgent  needs  of  an  increased  army  and 
navy  for  men  to  serve  in  the  medical  department?  Why  this 
apathy  ?  Why  this  holding  back  when  it  is  so  clearly  patent  that 
medical  men  are  sorely  needed  in  order  that  our  government  can 
do  its  part  in  this  great  war?  It  may  be  that  it  is  from  failure  to 
realize  the  needs  that  are  so  clearly  apparent.  It  may  be  that 
many  of  us  assume  that  the  war  is  nearly  at  an  end  and  there- 
fore the  needs  are  exaggerated.  It  may  be  that  indi- 
vidual selfishness  has  taken  the  place  of  patriotism.  Whatever  be 
the  cause  it  is  a  well  known  fact  that  the  medical  profession  is 
behind  all  other  classes  in  enlistment,  and  the  number  required 
for  the  medical  reserve  from  which  to  make  a  selective  draft  is 
woefully  over  and  above  the  number  enrolled ;  20,000  are  needed, 
of  which  only  4,000  are  enrolled.  Every  physician  in  this  country 
between  the  ages  of  25  and  55  should  without  delay  offer  his 
services  to  the  government.  If  accepted  he  should  be  ready  to 
serve  wherever  assigned.  Patriotism  is  not  true  patriotism  with- 
out some  sacrifice.  If  the  men  of  whom  our  great  army  and 
navy  are  composed  are  ready  to  give  up  their  lives  if  necessary 
for  their  country  surely  members  of  our  noble  profession  should 
be  ready  to  give  up  their  home  comforts  and  emoluments  to  prcn 


212     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

tect  these  men  in  war  wounds  and  disease.  From  an  estimate  of 
the  American  Medical  Asso.  Journal  we  learn  that  the  number 
of  graduates  from  the  various  medical  colleges  in  this  country  in 
the  last  six  years — 1912-1917  inclusive,  there  were  graduated 
22,478.  Leaving  out  of  this  number  the  women  graduates  and 
the  deaths  among  all  the  graduates  in  the  time  specified  there 
would  remain  the  goodly  number  of  20,000  young  doctors  be- 
tween the  ages  of  25  and  35  from  which  a  selective  draft  could 
be  made.  There  should  be  no  difficulty  in  securing  the  needed 
number  for  the  medical  reserve  if  conscription  were  made  up 
from  this  number  alone.  In  this  connection  we  take  pleasure  in 
presenting  below  two  circular  letters  prepared  by  the  Committee 
of  National  Defense,  medical  section,  issued  to  the  profession  of 
the  State  of  North  Carolina.  These  circulars  show  an  activity 
which  is  highly  commendable  and  deserving  of  imitation  by  all 
other  states.  Let  every  man  do  his  duty  should  be  the  slogan  of 
the  medical  profession  in  this  crisis : 

My  Dear  Doctor: 

I  am  writing  you  as  chairman  of  our  State  Committee,  believ- 
ing that  your  committee  might  be  interested  in  a  position  taken 
by  the  North  Carolina  State  Committee  on  National  Defense, 
Medical  Section.  In  a  recent  meeting  we  passed  the  following 
resolution : 

"Whereas,  The  justice,  wisdom,  and  efifectiveness  of  the  selec- 
tive draft  have  been  recognized  by  Congress  in  raising  a  strong 
army  from  our  civilian  population ;  and, 

"Whereas,  The  advantages  of  the  selective  draft  apply  with 
equal  force  to  securing  adequate  medical  service  for  the  army ; 
therefore,  be  it 

"Rosok'cd,  That  we,  the  North  Carolina  State  Committee  on 
National  Defense,  Medical  Section,  recommend  that  the  said  board 
use  its  influence  with  Congress  in  having  the  principles  of  the 
selective  draft  adopted  for  securing  an  adequate  medical  service 
for  the  army." 

The  resolution  speaks  for  itself.  The  objects  we  had  in  mind 
in  adopting  this  resolution  were  two :  ( 1 )  An  adequate  medical 


EDITORIALS  213 

service;  (2)  to  relieve  physicians  of  the  disagreeable  responsi- 
bility of  deciding  where  their  professional  services  are  most 
needed  under  the  circumstances.  It  is  embarrassing  to  certain 
physicians  whom  everybody  recognizes  are  most  needed  at  home 
to  be  required  to  make  that  decision  themselves;  moreover,  such 
physicians  are  ready  to  go  to  the  front  if  the  Government  decides 
that  they  are  needed  there. 

We  would  be  very  glad  if  your  State  committee  could  agree 
with  us  in  the  position  that  we  have  taken  in  this  all  important 
matter.  If  your  committee  should  agree  with  us,  we  would  ap- 
preciate your  sending  us  a  copy  of  the  resolution  which  you  adopt 
and  transmit  to  Dr.  Franklin  Martin. 

Very  respectfully  yours, 

J.  W.  Long,  M.D., 

Chairman  State  Committee  on  National  Defense,  Medical  Section. 

My  Dear  Doctor: 

In  addition  allow  me  to  add  this  personal  word.  You  know  as 
well  as  I  that  with  all  the  good  work  done  by  the  State  Commit- 
tees of  National  Defense,  Medical  Section,  we  have  not  succeeded 
in  getting  commissions  placed  in  the  hands  of  one-fourth  of  the 
number  of  physicians  that  will  be  needed  for  the  war.  Also,  that 
of  the  8,000  physicians  who  have  been  commissioned,  only  about 
3,000  have  accepted  their  commission.  To  not  accept  a  commis- 
sion is  to  make  it  as  ineffective  as  though  it  had  not  been  issued. 

Dr.  J.  C.  Bloodgood,  Chairman  of  the  Committee  on  Medical 
Preparedness,  Southern  Medical  Association,  with  whom  I  have 
been  in  conference  touching  the  matter,  advises  and  urges  that 
each  State  Chairman  of  the  Committees  of  National  Defense, 
Medical  Section,  call  his  committee  together  and  ask  them  to 
endorse  the  movement  of  the  selective  draft  for  physicians.  He 
believes,  as  I  do,  that,  if  a  majority  of  the  State  Committees  will 
adopt  the  North  Carolina  resolution,  or  something  similar,  and  it 
should  meet  the  approval  of  the  Surgeons  General  of  the  Army, 
Navy  and  Public  Health  Service,  our  General  Medical  Board  of 
the  Council  of  National  Defense  would  present  the  matter  before 
Congress  and  urge  its  adoption.     It  seems  clear  that  this  is  the 


214     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

only  solution  of  the  problem  of  an  adequate  supply  of  physicians 
for  the  service. 

Remember  that:  "The  King's  business  requireth  haste." 
Requesting  that  you  kindly  advise  me  of  your  action  in  the 
matter  and  with  personal  regards,  I  beg  to  remain, 

Sincerely  yours, 

J.  W.  Long,  M.D., 
Major,  Medical  Reserve  Corps,  U.  S.  A.,  Chairman  State  Com- 
mittee, National  Defense. 


Do  You  Know  That 


Keeping  health  is  a  part  of  doing  "your  bit?" 

Universal  public  health  service  is  the  duty  of  the  Nation? 

Much  valuable  food  material  is  diverted  in  the  manufacture 
of  alcoholic  beverages? 

The  only  good  fly  is  the  dead  one? 

Good  health  is  the  foundation  of  personal  usefulness  either  in 
peace  or  in  war? 

He  who  is  too  busy  to  care  for  his  health  may  have  to  take  time 
to  cure  disease? 


Resolution  of  the  American  Society  for  the 
Control  of  Cancer. 


Washington,  D.  C,  January  28,  1917 — A  letter  recently  re- 
ceived by  Director  Sam  L.  Rogers  of  the  Bureau  of  the  Census, 
Department  of  Commerce,  from  Mr.  Curtis  E.  Lakeman,  execu- 
tive secretary  of  the  American  Society  for  the  Control  of  Cancer, 
conveys  the  information  that  the  National  Council  of  that  society, 
at  its  meeting  at  the  Harvard  Club,  New  York  City,  on  June  4, 
1917,  unanimously  adopted  the  following  resolution: 

Resolved,  That  the  American  Society  for  the  Control  of  Can- 
cer strongly  commends  the  action  of  the  U.  S.  Bureau  of  the  Cen- 
sus in  publishing  its  notable  report  on  the  mortality  from  cancer 
in  the  U.  S.  Registration  Area  in    1914,  and  records  its  apprecia- 


EDITORIALS  •  215 

tion  of  the  courteous  cooperation  of  the  Director  of  the  Census 
and  all  the  members  of  his  stafif  who  contributed  to  the  compila- 
tion of  this  unique  volume,  which  represents  an  unparalleled  con- 
tribution to  the  statistical  study  of  malignant  disease,  and  has 
already  furnished  the  basis  for  many  promising  special  investiga- 
tions.'' 


Editor  Nashville  Journal  of  Medicine  and  Surgery,  Nashznlle. 

Dear  Sir  —  I  am  leaving  for  France  as  neurologist  in  the 
French  service.  Expect  to  return  in  October,  1918.  Kindly  send 
my  journal  to  Dr.  E.  G.  Mitchell,  15  7th  Street,  N.  E.,  Washing- 
ton, D.  C.  Please  announce  my  departure  and  that  patients  and 
communications  are  to  be  referred  to  Dr.  Mitchell  until  my  re- 
turn. Yours  faithfully, 

Tom  a.  Williams. 


Children  ix  W^ar  Time. 


Third  Article:  How  Canada  Takes  Care  of  Soldiers'  Children. 
Washington,  June  30 — How  Canada  provides  for  the  wives 
and  children  of  her  enlisted  men  is  described  in  a  report  by  Mr. 
S.  Herbert  Wolfe  of  New  York,  prepared  at  the  request  of  the 
Secretary  of  Labor  and  just  published  by  the  Children's  Bureau 
of  the  U.  S.  Department  of  Labor. 

In  presenting  the  report,  Miss  Lathrop,  Chief  of  the  Children's 
Bureau,  says : 

'Tn  the  fifty  years  since  the  Civil  War,  legislation  affecting  the 
family  and  its  economic  status  has  shown  marked  growth.  Moth- 
ers' pension  laws  and  minimum-wage  laws  are  recognized  exam- 
ples, and  it  is  acknowledged  that  their  result  has  not  been  to  pau- 
perize but  distinctly  to  improve  the  power  of  the  family  to  pro- 
tect itself.  In  view  of  this  tendency  it  is  to  be  expected  that  a 
system  of  compensation  for  soldiers  and  sailors  can  be  developed 
whereby  the  Government  will  make  possible  for  their  children 


216      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

the  home  life  and  parental  care  which  are  the  common  need  of 
every  child." 

The  report  points  out  that  in  Canada  two  notable  elements 
have  been  added  to  the  government  provision  for  soldiers  and 
their  families :  First,  insurance  on  the  lives  of  soldiers  is  carried 
by  various  municipalities,  and,  second,  the  Dominion  has  under- 
taken as  a  part  of  its  military  system  the  reeducation,  in  a  suit- 
able occupation,  of  the  disabled  soldier  so  that  he  can  assume 
again,  in  whole  or  in  part,  the  care  of  his  family. 

The  Canadian  compensation  for  the  soldier  and  his  family  in- 
cludes not  only  $33  of  monthly  pay  for  the  private  in  active  ser- 
vice, but  a  separation  allowance  to  his  dependents  of  $20  a  month 
from  the  Dominion  Government  and  further  assistance  in  special 
cases  from  the  Canadian  Patriotic  Fund. 

For  example,  the  wife  of  a  private  soldier  with  three  children 
between  the  ages  of  10  and  15  may  receive  either  $15  or  $20  from 
the  assigned  pay  of  her  husband,  $20  separation  allowance,  and 
$25  from  the  Canadian  Patriotic  Fund,  or  in  all  $60  or  $65  a 
month. 

If  her  husband  is  killed,  she  will  receive  $40  a  month  for  her- 
self, and  an  additional  $6  a  month  for  each  of  her  children  until 
her  boys  are  16  years  of  age  and  her  girls  are  17  years  of  age. 
In  addition,  if  she  lives  in  Toronto  or  one  of  a  number  of  other 
cities,  she  will  receive  life  insurance.  This  will  be  paid  to  her  in 
monthly  installments  unless  she  shows  that  she  needs  the  entire 
amount  at  once  to  pay  ofif  a  mortgage  or  to  make  a  start  in 
business. 

If  her  husband  is  disabled,  she  will  receive  a  special  mainte- 
nance allowance  while  he  is  having  medical  treatment  and  learn- 
ing a  new  occupation,  and  when  he  is  finally  discharged,  if  his 
physical  disability  continues,  a  pension  will  be  paid  according  to 
the  extent  of  his  disability  and  the  number  of  his  children  under 
16  or  17  years  of  age. 

Mr.  Wolfe  is  an  actuary  of  recognized  authority  and  he  has 
analyzed  especially  the  municipal  provision  for  life  insurance  by 
which  certain  Canadian  cities  have  supplemented  the  pensions 
provided  by  the  Dominion  for  dependents  of  deceased  soldiers. 


EDITORIALS  217 

In  Toronto,  the  municipality  has  not  only  purchased  $10,000,000 
worth  of  insurance  from  private  companies,  but  it  is  itself  carry- 
ing more  than  $32,000,000  worth  of  insurance.  A  municipal  in- 
surance bureau  has  been  organized  and  $2,000  worth  of  bonds 
have  been  issued  of  which  the  principal  and  interest  are  a  charge 
upon  the  general  taxpayers  of  the  city.  Every  officer  and  en- 
listed man  residing  within  the  city  limits  of  Toronto  who  volun- 
teers for  oversea  service  has  from  the  date  of  his  enlistment  been 
protected  by  a  life  insurance  policy  of  $1,000,  the  protection  run- 
ning from  the  time  of  his  enlistment  to  his  death  or  six  months 
after  his  discharge  or  resignation. 

The  report  refers  alsD  to  the  fact  that  each  of  the  European 
countries  makes  government  provision  for  the  families  of  private 
soldiers  and  sailors.  In  Great  Britain,  France  and  Germany  the 
amount  of  the  governmental  separation  allowance  depends  upon 
the  size  of  the  family  which  must  be  supported. 


Children's  Pl.av — A  P.\triotic  Call. 


Washington,  June  30,  1917 — Public  provision  for  recreation  is 
not  a  luxury  to  be  cut  off  but  a  necessity  to  be  conserved.  Miss 
Julia  C.  Lathrop,  Chief  of  the  Children's  Bureau  of  the  U.  S. 
Department  of  Labor,  in  discussing  the  report  on  Facilities  for 
Children's  Play  in  the  District  of  Columbia,  which  has  just  been 
issued  by  the  Bureau,  said  today: 

"An  English  authority  has  lately  pointed  out  the  demoraliza- 
tion to  boys  and  girls  caused  by  the  breaking  down  of  clubs  and 
the  withdrawal  to  the  army  of  recreation  leaders,  and  he  has 
traced  much  of  the  increase  in  juvenile  delinquency  in  England 
to  the  chaos  in  recreation  activities  which  has  prevailed  since  the 
war. 

"This  is  a  good  time  to  remind  ourselves  that  the  continuance 
and  development  of  all  types  of  innocent  and  healthful  recrea- 
tion in  every  community  offer  a  call  to  patriotic  service  for  many 
who  can  not  go  to  the  front.  The  strain  and  anxiety  which  are 
certain  to  grow  in  this  country  for  an  indefinite  period  ahead  of 


218     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

us  need  to  be  counterbalanced  by  greater  community  efifort  to 
provide  opportunity  for  wholesome  play." 

The  report  on  children's  play  in  Washington  describes  the  va- 
rious sections  of  the  city  and  the  extent  of  the  playgrounds  and 
athletic  fields  provided  by  the  District  Government,  by  the  public 
schools,  and  in  connection  with  the  Federal  parks.  It  includes  an 
analysis  of  distances  and  population  in  relation  to  play  facilities 
and  makes  recommendations  for  the  further  development  of  rec- 
reation in  Washington. 


Miners'  Consumption. 


A  recent  investigation  of  the  causes  and  prevalence  of  miners' 
consumption  among  the  metal  miners  in  Southwestern  Missouri 
forms  the  subject  of  Public  Health  Bulletin  Xo.  85,  issued  by  the 
U.  S.  Public  Health  Service. 

Miners'  consumption  consists  essentially  of  a  mechanical  injury 
to  the  lungs  due  to  the  prolonged  inhalation  of  hard  rock  dust. 
It  has  been  recognized  as  being  prevalent  in  some  American  min- 
ing districts,  particularly  in  the  Joplin  zinc  and  lead  districts.  It 
was  to  determine  its  actual  prevalence,  and  its  relationship  to  pul- 
monary tuberculosis  that  the  investigation  was  undertaken. 

In  the  Joplin  district  certain  mines  are  known  as  "sheet-ground" 
mines,  in  which  the  ore  is  found  imbedded  in  an  exceedingly 
hard  flint.  In  drilling  and  other  mining  operations  this  flint  rock 
is  finely  pulverized.  The  minute  rock  dust  particles  enter  the 
lungs,  in  the  process  of  natural  breathing,  and  by  their  irritating 
action  cause  the  formation  of  fibrous,  or  scar-like,  tissue.  The 
effect  of  this  is  to  lessen  the  lungs'  ability  to  expand  and  contract, 
with  the  result  that  the  victim  first  notices  that  he  is  becoming 
short  winded.  W^ith  continued  exposure  to  this  silica  containing 
dust,  the  difficulty  of  breathing  increases,  until  the  miner  is  no 
no  longer  able  to  perform  active  physical  labor.  It  was  found 
also  that  men  with  dust-injured  lungs  were  especially  liable  to 
develop  tuberculosis,  the  dust  irritation  lessening  the  ordinary 
resisting  powers  of  the  lungs.  While  miners'  consumption  is  not 
in  itself  infectious  or  contagious,  it  predisposes  to  tuberculosis. 


EDITORIALS  219 

The  greater  the  amount  of  rock  dust  injury  the  greater  the  Ha- 
bihty  to  tuberculosis ;  the  far  advanced  cases  of  miners'  con- 
sumption practically  all  become  tuberculous  before  their  death. 

Under  an  entirely  voluntary  system  720  miners  presented 
themselves  for  physical  examination,  of  whom  433  were  found 
to  have  had  their  lungs  injured  by  the  inhalation  of  rock  dust : 
of  these  103  were  also  tuberculous,  the  amount  of  tuberculosis  in- 
fection being  greatest  among  the  advanced  cases  of  the  rock  dust 
disease. 

Five  years  steady  work  with  exposure  to  flint  dust  is  fairly  cer- 
tain to  find  the  miner  m  at  least  the  first  stages  of  miners'  con- 
sumption. If  the  miner  continues  his  work  after  being  affected, 
death  usually  results  within  ten  years  from  the  time  that  exposure 
to  flint  dust  commenced.  Poor  housing  conditions  were  found 
to  be  prevalent  and  to  add  to  the  liability  of  tuberculosis  infec- 
tion. Apparently  tuberculosis  is  now  occurring  at  an  earlier  stage 
of  miners'  consumption  than  was  formerly  the  case.  The  report 
lays  emphasis  on  the  necessity  of  preventing  the  spread  of  tuber- 
culosis through  these  cases,  especially  among  miners'  children. 
The  fact  that  miners'  consumption  is  a  forerunner  of  tuberculosis 
necessitates  that  it  be  treated  with  the  same  hygienic  precautions 
as  is  the  latter  disease. 

The  report  concludes  that  aside  from  the  hygienic  supervision 
of  underground  working  places,  the  education  of  the  miner 
against  the  spread  of  infection  and  supervision  of  miners'  chil- 
dren, especially  those  of  consumptive  parents,  are  matters  of  vital 
importance. 


The  National  Committee  for  Mental  Hygiene  has  created  a 
sub-committee  on  furnishing  hospital  units  for  nervous  and  men- 
tal disorders  to  the  United  States  Government,  the  project  having 
been  approved  by  Surgeon  General  W.  C.  Gorgas  of  the  U.  S. 
Army. 

This  subcommittee,  of  which  Dr.  Pearse  Bailey  of  New  York 
is  chairman,  is  authorized  to  secure  the  services  of  alienists  and 
neurologists  to  be  commissioned  in  the  Ofhcers'  Reserve  Corps, 


220     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Medical  Section,  and  to  serve  in  the  neuro-psychiatric  units  which 
are  to  be  attached  to  the  base  and  other  hospitals  of  the  military 
services  of  the  United  States.  Further  information  will  be  given, 
and  application  forms  sent  to  physicians  qualified  in  this  branch 
of  medicine,  on  application  by  letter  or  in  person  to  The  National 
Committee  for  Mental  Hygiene,  50  Union  Square,  New  York 
City. 


As  leading  article  of  this  issue  we  present  a  valuable  paper  by 
Dr.  J.  W.  Long  of  Greensboro,  N.  C,  which  appeared  in  the 
March  17th  issue  of  the  Journal  of  the  American  Medical  Asso- 
ciation. We  regret  that  we  failed  to  secure  the  cuts  which  illus- 
trated the  original  publication,  but  the  text  is  so  clear  as  really 
not  to  require  illustration. 


REVIEWS  AND  BOOK  NOTICES  221 


i&eimhifi  unh  look  Natir^B 


Physical  Exercises  for  Invalids  and  Convalescents — By  Edward  H. 
Ochsner,  B.S.,  M.D.,  F.  A.  C.  S.,  President  Illinois  State  Charities 
Commission,  Attending  Surgeon  Augustana  Hospital,  Chicago.  Illus- 
trated.    St.  Louis.    C.  V.  Mosby  Company,  1917. 

This  little  handbook  should  prove  of  practical  use  to  the  prac- 
titioner in  furnishing  a  guide  to  the  patient  needing  it  to  a  course 
of  exercises  designed  to  overcome  muscular  deficiencies  occa- 
sioned by  various  diseases.  The  little  work  is  copiously  illus- 
trated throughout  by  diagrams  with  clear  and  concise  text  show- 
ing the  various  movements  necessary  for  development.  Every 
practitioner  should  have  this  guide,  as  by  means  of  it  he  can 
provide  his  patient  with  a  full  set  of  instructions  for  ttseful  ex- 
ercises. 


Progressive  Medicine — A  Quarterly  Digest — Advances,  Discoveries  and 
Improvements  in  the  Medical  and  Surgical  Sciences.  Edited  by 
Hobart  Amory  Hare,  M.D.,  Professor  of  Therapeutics,  Materia  Medica 
and  Diagnosis  in  the  Jefferson  Medical  College,  Philadelphia.  As- 
sisted by  Leighton  F.  Appleman,  M.D.,  Instructor  in  Therapeutics, 
Jefferson  Medical  College,  Philadelphia.  June  1,  1917.  Owners  and 
Publishers,  Lea  &  Febiger,  Philadelphia,  New  York. 

We  acknowledge  with  thanks  to  the  obliging  publishers  the  re- 
ceipt of  this  number  of  the  well  known  quarterly  publication. 
This  number  is  full  of  attractive  and  instructive  matter  and  rep- 
resents the  last  word  in  the  advance  of  the  subjects  treated  of. 
The  contributors  to  this  number  are  well  known  authorities  upon 
the  subjects  to  which  they  have  been  assigned  and  it  is  conceded 
that  these  subjects  are  brought  well  to  date.  The  physician 
who  desires  to  keep  in  the  van  guard  should  certainly  become  a 
subscriber  to  this  great  serial.  The  contents  with  authors  are  as 
follows:  Hernia,  by  Wm.  B.  Coley,  M.D. ;  Surgery  of  the  Abdo- 
men Exclusive  of  Hernia,  by  John  C.  A.  Gerster,  M.D. ;  Gyne- 
cology, by  John  G.  Clark,  M.D. ;  Diseases  of  the  Blood,  Diathetic 
and  Metabolic  Diseases,  Diseases  of  the  Thyroid  Gland,  Spleen 
and  Nutrition,  and  the  Lymphatic  System,  by  Alfred  Stengel, 
M.D. ;  Ophthalmology,  by  Edward  Jackson,  M.D. ;  Index. 


222     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Roentgen  Technic  (Diagnostic) — By  Norman  C.  Prince,  M.D.,  Attend- 
ing Roentgenologist  to  the  Omaha  Free  Dental  Dispensary  for  Chil- 
dren; Roentgenologist  to  the  Douglas  County  Hospital,  Bishop  Clark- 
son  Memorial  Hospital,  Swedish  Immanuel  Hospital,  St.  Joseph  Hos- 
pital and  Ford  Hospital,  Omaha,  Neb.  With  Seventy-one  Original 
Illustrations.     St.  Louis.     C.  V.  Mosby  Company,  1917. 

This  small  volume  should  prove  of  the  greatest  value  to  every 
physician  who  does  any  work  with  the  X-ray  apparatus.  The 
author  evidently  has  had  a  very  extensive  experience  with  this 
branch  of  diagnostic  work  and  is  well  fitted  to  point  out  the  way 
to  everyone  interested  in  this  important  aid  to  diagnosis.  The 
work  is  freely  illustrated  throughout  and  the  text  of  the  work  is 
clear  and  concise.  It  is  essentially  a  guide  book  for  the  use  of 
the  Roentgen  ray  apparatus  in  accomplishing  diagnosis  and  as 
such  it  will  prove  practically  useful  to  every  one  needing  such 
aid.  We  have  examined  the  work  ver)-  closely  and  can  con- 
scientiously recommend  it  to  the  profession. 


PUBLISHERS'  DEPARTMENT  223 


^ublishpr'fi  i^parlmrnl 


Are  You  Seeking  a  Reliable  Tonic/ 


Conservative  medical  men  are  neither  asked  nor  expected  to  accept  the 
opinions  or  conclusions  of  anyone  else  concerning  the  value  of  Gray's 
Glycerine  Tonic  Comp.  The  only  request  of  the  manufacturers  is  that 
the  physician  who  is  seeking  a  tonic,  a  dependable  means  of  restoring  the 
activity  of  the  bodily  functions,  will  give  this  remedy  a  fair  and  reason- 
able trial.  To  his  conclusions  as  to  the  results  obtained — his  judgment  as 
to  the  superiority  of  this  remedy  as  a  means  of  overcoming  debility,  inani- 
tion and  malnutrition — the  decision  as  to  its  use  in  the  treatment  of  de- 
bilitated conditions  is  cheerfully  left.  Knowledge  of  what  careful,  pains- 
taking physicians,  however,  are  doing  with  Gray's  Glycerine  Tonic  Comp. 
whenever  a  tonic  is  indicated,  leaves  no  doubt  of  what  that  judgment  will 
be,  for  it  has  been  shown  beyond  all  possible  question  that  this  efficient 
therapeutic  agent  has  no  superior  in  its  field  of  use. 

If  you  have  some  troublesome  case  in  which  you  would  like  to  try 
"Gray's" — write  today  to  the  Purdue  Frederick  Company,  135  Christopher 
St.,  New  York  City. 


"Robinson's  Lime  Juice  and  Pepsin"  is  an  excellent  remedy  in  the  gas- 
tric derangements  particularly  prevalent  at  this  season.  It  is  superior  as 
a  digestive  agent  to  many  other  similar  goods.  (See  advertisement  in 
this  issue.) 


More  than  thirty  years  ago  a  prominent  physician  of  St.  Paul  made  the 
following  statement,  which  has  since  been  corroborated  by  the  clinical 
experience  of  thousands  of  physicians : 

"For  the  indefinite  aches  and  pains  of  nervous  patients  Tongaline  is 
superior  to  any  other  anodyne.  For  nervous  headache  or  musclar  elimi- 
nation it  is  almost  a  specific." 


Discrimination  in  the  Use  of  Opiates. 


Some  pains  are  so  acute  and  unresponsive  to  the  simpler  anodynes  that 
recourse  to  an  opiate  must  be  had.  Most  physicians  recognize  the  need  of 
careful  choice  in  the  administration  of  opium  preparations,  the  desire  to 
guard  against  disturbing  the  normal  function  as  far  as  possible  and,  what 
is  of  just  as  much  importance,  avoiding  the  formation  of  a  habit. 

In  PAPIXE  (Battle)  the  physician  will  find  an  opiate  of  the  highest 
worth  and  one  that  will  subject  the  patient  to  the  least  harm.  It  is  a 
purified  product  of  opium. 


224     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

When  the  Tissues  Need  Nourishment. 


For  chronic  anemic  conditions  due  to  disordered  metabolism,  Cord. 
Ext.  Ol.  Morrhuae  Comp.  (Ilagee)  shows  its  marked  power  to  supply 
nourishment  to  the  tissues. 

The  advantage  Cord.  Ext.  01.  Morrhuae  Comp.  (Hagee)  possesses  over 
the  ordinary  cod  liver  oil  products  is  based  upon  its  palatability  and  ease 
of  assimilation.  At  a  result  it  may  be  given  for  long  periods  without 
causing  gastric  disturbances.  Although  agreeable,  Cord.  Ext.  Ol.  Mor- 
rhuae Comp.  (Hagee)  possesses  the  full  nutritive  and  therapeutic  quali- 
ties of  the  plain  oil. 


Taking  Up  the  Slack. 


Taking  up  the  nervous  slack  after  an  alcoholic  debauch  is  one  of  the 
prime  purposes  of  PASADYXE  (Daniel).  In  the  extreme  nervousness 
and  sleeplessness  consequent  upon  alcoholic  saturation  of  the  brain  PAS- 
ADYXE (Daniel)  is  of  the  utmost  value,  and  is  much  resorted  to  by 
practical  men  who  handle  this  class  of  cases.  The  sleep  secured  is  re- 
freshing and  enables  the  poor  deluded  alcoholic  to  get  a  grip  on  himself 
once  again. 

A  sample  bottle  of  PASADYNE  may  be  had  by  addressing  the  labor- 
atory of  John  B.  Daniel,  Inc.,  Atlanta,  Ga. 


In  Pruritus. 


Even  in  severe  forms  of  genital,  anal,  diabetic,  eczematous  itching,  K-Y 
Lubricating  Jelly  in  a  great  majority  of  cases,  will  bring  relief,  or  at  least 
grateful  alleviation. 

To  anoint  the  skin  in  these  conditions,  K-Y  Lubricating  Jelly  is  not 
only  effective,  but  convenient  and  economical,  since  it  can  be  used  without 
staining  or  soiling  the  bed  clothes  or  the  patient's  linen.  If  the  part  is 
washed  before  each  application,  the  best  results  are  obtained. 


In  Neuritis,  is  the  hot  water  bottle  the  best  anodyne?  Palliation,  by 
means  of  externally  applied  heat,  is  just  as  popular  today  as  it  was  in 
Hippocrates'  time. 

The  hot  bath  and  the  hot  water  bottle  are  wonderful  comforters.  But 
who  can  be  continuously  in  the  bathtub,  or  who  can  be  forever  carrying 
a  hot  water  bottle?  And  how  all  too  soon  does  the  most  faithful  hot 
water  bottle  lose  its  odor  and  its  temperature ! 

There  is  no  simple  adjunct  in  this  category  more  simple  and  more  gen- 
uinely effective  than  application  by  the  patient  himself,  is  possible  along 
the  course  of  the  affected  nerve,  with  K-Y  ANALGESIC  (methyl-salicy- 
late,  camphor  and  menthol,  combined  in  a  non-greasy,  water-soluble  base.) 

K-Y  ANALGESIC  has  the  obvious  advantage  over  the  hot  water  bot- 
tle in  that  "it  stays  put"  for  a  much  greater  period  of  time.  Nor  is  there 
the  possible  danger  of  a  hot  water  bottle  burn — a  factor  especially  to  be 
thought  of  where  the  neuritis  patient  is  weak  and  infirm. 


\\ 


NASHVILLE  JOURNAL 

OF  

MEDICINE  AND    SURGERY 


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


Vol.  CXI.  AUGUST,  1917.  No.  8 


(ingtnal  QlnmmumrattonB 


THE  DIAGNOSIS  OF  URETERAL  CALCULI  —  A  PLEA 
FOR  THE  USE  OF  THE  WAX-TIPPED  CATHETER. 


BY   HOWARD  S.   JECK,  PH.   B.,   M.D. 

Attending  Cystoscopist,  St.  Johns  Hospital  Brooklyn,  and  Sur- 
geon to  the  Cornell  Clinic,  New  York. 


While  the  symptoms  of  stone  in  the  ureter  are  oftentimes  so 
typical  as  to  permit  of  an  almost  positive  diagnosis,  still  no  sur- 
geon feels  justified  in  instituting  a  radical  procedure  for  its  re- 
moval until  more  definite  evidence  of  the  presence  of  stone  is  ob- 
tained. To  this  end.  we  still  resort  to  the  X-ray  as  our  one  most 
valuable  adjunct,  but  its  failure  to  show  the  presence  of  calculi  at 
times  and  the  frequent  mistakes  which  result  in  the  interpretation 
of  radiographs  where  a  stone  is  actually  present,  make  an  addi- 
tional diagnostic  measure  not  only  very  welcome  but  in  some  in- 
stances an  absolute  necessity. 

Pure  viric  acid  calculi  or  very  small  calculi  of  any  composition 
may  be  missed  entirely  by  the  most  skillful  of  radiographers. 
Fortunately  the  former,  without  an  admixture  of  oxalates  or  phos- 
phates are  very  rare,  while  minute  calculi  do  not  tax  our  diagnos- 


226      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

tic  skill,  because  they  are  likely  to  be  passed  with  the  consequent 
disappearance  of  symptoms. 

It  is  my  purpose  in  this  paper  to  briefly  set  forth  the  advantages 
of  the  wax-tipped  ureteral  bougie  or  catheter  when  used  in  those 
instances  when  the  symptoms  clearly  point  to  ureteral  calculus, 
and  where  the  X-ray  either  leaves  one  in  doubt  or  else  fails  en- 
tirely to  throw  a  shadow. 

Kelly  of  Johns  Hopkins  has  used  wax-tipped  bougies  for  sev- 
eral years  with  marked  success.  But  his  method  of  direct  cys- 
toscopy limits  this  adaptability  to  women  alone.  And  while  many 
urologists  employ  the  wax-tipped  catheter  with  more  or  less  suc- 
cess, still  there  is  somehow  the  prevailing  impression  that  it  is 
almost  worthless  as  a  diagnostic  measure.  This  may  be,  in  part, 
due  to  "accidental  scratches",  brought  about  by  improperly  intro- 
ducing the  wax-tip  into  the  bladder  and  ureter. 

During  the  past  eighteen  months  I  have  seen  at  least  eight  cases 
of  ureteral  calculus  where  the  diagnosis  was  confirmed  by  the 
wa.x-tipped  catheter.  I  shall  detail  the  most  striking  case  of  this 
series,  since  to  me  it  seems  to  speak  volumes  in  favor  of  this  means 
of  diagnosis. 

Dr.  B.  S.  Barringer,  with  whom  I  am  associated,  had  the  kind- 
ness to  call  my  attention  to  3^1  rs.  J.  F.  C,  aged  40,  who  com- 
plained of  attacks  of  renal  colic.  She  had  suffered  her  last  attack 
one  week  before  coming  to  our  office.  So  plainly  did  the  symp- 
toms point  to  stone  in  the  urinary  tract  that  Dr.  Barringer  had 
her  promptly  X-rayed  and  obtained  the  following  report : 

"Directly  in  line  with  the  left  ureter  there  is  a  clean-cut,  well- 
defined  shadow  which  lies  just  outside  the  bladder.  The  size, 
shape  and  position  of  this  shadow  is  strongly  significant  of  a  cal- 
culus lying  in  the  ureter  close  to  the  bladder.  There  is  a  pos- 
sibility of  its  being  outside  the  ureter,  but  its  appearance  is  in 
favor  of  its  being  within  the  ureter.  I  believe  it  is  of  such  size 
and  shape  that  there  is  a  great  probability  of  its  passing  into  the 
bladder." 

Upon  receiving  this  report,  the  patient  was  promptly  cysto- 
scoped.  The  bladder  appeared  to  be  normal  and  a  saturated  solu- 
tion of  indigo-carmine  injected  intravenously  showed  up  promptly 


ORIGINAL  COMMUNICATIONS  227 

and  strong  from  both  ureters.  A  wax-tipped  catheter  passed  into 
the  left  ureter  received  a  distinct  scratch,  which  Dr.  E.  L.  Keyes, 
Jr.,  Dr.  Barringer  and  I  all  agreed  was  caused  by  a  stone  and  was 
not  accidental.  A  week  later  a  few  "bites"  were  taken  in  the  left 
ureteral  orifice  in  order  to  enlarge  it,  by  means  of  the  Burerger 
operating  forceps. 

Soon  thereafter  the  patient  had  two  attacks  of  ureteral  colic, 
and  a  month  later  she  was  again  X-rayed,  with  the  following 
findings : 

"There  is  a  clear-cut,  well  defined  shadow  near  the  lower  end 
of  the  left  ureter  and  the  long  axis  corresponds  with  the  axis  of 
the  ureter.  When  the  plates  are  compared  with  those  made  at 
the  original  examination,  the  shadow  is  shown  to  be  in  the  same 
position  as  previously,  and  in  spite  of  the  ureteral  colic,  there  is 
no  evidence  of  its  having  moved." 

Another  wax-tipped  catheter  was  passed  after  receiving  the 
above  report  and  another  typical  scratch  was  obtained. 

At  this  time  the  left  ureteral  mouth  was  -nci^ed  by  the  Buerger 
operating  scissors  and  a  14F  bougie  passed  into  the  ureter.  Im- 
mediately following  this  dilatation,  the  patient  had  se-veral  severe 
attacks  of  colic  and  returned  in  about  three  weeks  for  another 
examination.  For  the  third  time  a  wax-tipped  catheter  was  pass- 
ed, and  for  the  first  time  no  scratch  teas  obtained.  The  patient 
was  again  radiographed  at  once  and  the  following  findings  were 
reported : 

"The  shadow,  which  was  distinctly  shown  in  the  previous  plates 
in  the  region  of  the  lower  end  of  the  left  ureter  is  absent  on  these 
plates.  Therefore  I  feel  justified  in  stating  with  certainty  that 
the  calculus  has  passed  out  of  the  urinary  tract." 

The  urine  analysis  at  this  time  showed  a  faint  trace  of  albumen, 
no  sugar,  a  very  few  red  blood  cells,  and  no  pus. 

Nearly  six  months  have  now  elapsed  since  the  patient's  last  at- 
tack of  ureteral  colic.  There  have  likewise  been  no  other  symp- 
toms. And  while  no  stone  was  ever  noticed  in  her  urine,  still  we 
think  it  is  only  fair  to  conclude  that  from  her  typical  symptoms, 
X-rav  and  scratches,  which  coincided  every  time  with  the  X-ray 


228      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

findings,  there  z\.'as  a  stone  beyond  the  shadow  of  a  doubt,  and 
that  it  probably  passed  at  her  last  attack  of  ureteral  colic. 

Converts  to  the  wax-tip  method  are  not  easily  won.  To  me  it 
seems  that  the  secret  of  possessing  confidence  in  the  method  lies 
in  one's  assurance  that  he  employs  a  technique  whereby  the  cath- 
eter is  not  scratched  accidentally.  Such  assurance  will  not  be 
forthcoming  if  one  introduces  the  cystoscope  in  the  ordinary  way 
and  then  attempts  to  pass  the  catheter.  For  it  is  almost  impos- 
sible to  do  this  without  getting  an  accidental  scratch.  My  way  is 
to  feed  the  wax-tipped  catheter  backzuards  into  the  cystoscope 
with  the  telescope  in  place  until  the  wax-tip  projects  two  or  three 
inches  beyond  the  end  of  the  cystoscope.  The  latter  is  then  in- 
troduced in  the  ordinary  manner  but  with  greater  care  than  usual, 
as  the  use  of  the  obturator  is  precluded  and  hence  the  introduction 
is  made  much  more  difficult,  especially  in  the  male.  Indeed,  in 
some  instances  I  have  found  it  quite  impossible  to  introduce  the 
ordinary  24F  cystoscope  without  the  obturator.  In  such  cases, 
however,  I  have  never  failed  to  introduce  the  18F  single  catheter- 
izing  cystoscope  and  have  now  adopted  the  plan  of  trying  the  lat- 
ter first,  provided  the  condition  of  the  bladder  is  such  that  the 
limited  scope  of  the  smaller  instrument  will  not  be  a  detriment  in 
finding  and  catheterizing  the  suspected  ureter. 


EXTRACTS  FROM  JOURNALS  229 


ExtrartB  from  l^amt  nnh  Jnr? ign  SInurnalfl 


SURGICAL 


Ix  JURIES  TO  PaNXREAS. 


A  few  cases  have  been  observed  by  Young-  and  Colson  in  which 
extreme  abdominal  distension  followed  kidney  operations.  In  one 
of  them  it  was  found  _iiecessary  to  perform  an  enterostomy  for 
the  relief  of  the  obstruction,  following  which  the  patient  made  an 
uninterrupted  recovery.  The  remaining  cases  of  uncomplicated 
distension  yielded  rapidly  to  the  usual  simple  methods.  The  two 
cases  in  which  the  pancreas  had  suffered  injury  are  given  in  de- 
tail on  account  of  their  rarity  and  interest.  In  summary  they  are : 
Case  1.  Renal  calculus.  Right  nephrotomy.  Bleeding  from  ab- 
errant vessel,  stopped  by  blind  clamping  and  pressure.  Postop- 
erative intestinal  obstruction.  Enterostomy.  Death.  Necropsy : 
Pancreatitis,  fat  necrosis.  Case  2.  Right  renal  Calculus.  Op- 
eration ;  kidney  very  adherent  at  upper  pole ;  pyelotomy.  Post- 
operative intestinal  obstruction,  requiring  enterostomy.  Develop- 
ment of  glycosuria.  H  :  Pancreatin.  Slow  convalescence  and 
cure.  Another  case  was  an  example  of  severe  distension  leading 
to  intestinal  obstruction  which  is  not  infrequently  seen  after  right- 
sided  renal  operation.  However,  in  this  case  there  was  no  dem- 
onstrable injury  to  the  pancreas  either  at  the  time  of  the  enteros- 
tomy operation  or  in  the  subsequent  postoperative  course.  Case 
3.  Nephrectomy  for  large  hypernephroma.  Difficult  operation 
on  account  of  hemorrhage.  Postoperative  nausea,  vomiting  and 
distension.  Intestinal  obstruction  requiring  enterostomy  on  fifth 
day.    Recovery. 

The  authors  point  out  that  injury  to  the  pancreas  can  best  be 
avoided  by  an  adequate  incision  for  the  exposure  of  the  kidney 
and  careful  ligation  of  all  structures  divided  in  freeing  the  upper 
pole ;  and  the  probability  of  the  presence  of  anomalous  vessels 
must  be  kept  in  mind  and  care  taken  to  ligate  them  securely.     In- 


230      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

jury  to  the  pancreas  should  be  suspected  following  operation  on 
the  right  kidney  in  the  presence  of  extreme  abdominal  distension 
and  rapid  prostration.  Rapid  enterostomy  offers  a  chance  of 
preserving  life  by  relief  of  the  intestinal  obstruction,  but  if  the 
injury  is  extensive  enough  to  cause  widespread  extravasation  of 
pancreatic  secretion  the  condition  is  hopeless.  Traumatism  to  in- 
testine by  retractors,  clamps  or  gauze  packs  may  also  cause  intesti- 
nal distension  or  even  obstruction.  Care  in  hemostasis  and  good 
exposure  without  violent  retraction  and  traumatism  is  of  prime 
importance  in  renal  surgery. — Jour,  of  the  Am.  Med.  Asso. 


Radiother.\py  Plus  Operation  in  Treatment  of  Cancer. 


Nogier  says  he  has  been  appalled  at  the  histologic  findings  of 
cancer  cells  scattered  through  the  adjoining  tissues  after  appar- 
ently complete  excision  of  cancers.  Particularly  in  the  breast, 
improved  technic  has  revealed  cells  sown  through  the  tissue  far 
back  of  the  primary  tumor.  They  are  not  seen  nor  felt,  and  lie 
latent  till  after  the  operation.  This  arouses  them,  and  we  have 
recurrence  of  the  cancer.  For  this  and  other  reasons  he  advo- 
cates broad  and  intensive  radiotherapy  before  the  operation,  pre- 
operative instead  of  postoperative  Roentgen  or  radium  exposures. 
This  he  insists  will  prove  successful  beyond  anything  yet  realized 
to  date.  Working  with  Regaud,  he  has  conclusively  demonstrated, 
he  reiterates,  that  it  is  possible  to  give  enormous  doses  of  filtered 
Roentgen  rays,  leaving  the  skin  intact.  They  expose  the  cancer 
first,  then  the  adjoining  regions,  and  especially  the  lympth  glands 
which  are  ordinarily  invaded.  The  operation  should  be  as  early 
as  possible,  removing  all  the  microscopically  evident  malignant 
tissue.  The  scattered  cancer  cells  lose  all  power  for  reproduction 
under  the  exposures,  and  if  any  embolism  occurs  during  the  fol- 
lowing operation  the  embolus  is  sterile  and  metastasis  is  not  en- 
tailed. The  cells  in  the  depth  having  lost  their  power  of  repro- 
duction, die  off  sooner  or  later  and  are  absorbed.  This  absorp- 
tion of  cancer  cells  serves  as  an  immunizing  process.  All  the  evi- 
dence, therefore,  he  concludes,  is  overwhelmingly  in  favor  ol  ra- 


EXTRACTS  FROM  JOURNALS  231 

diotherapy  followed  by  excision  as  the  logical  treatment  for  can- 
cer.— The  Jour,  of  the  Aiiier.  Med.  Asso. 


Non-\'enere.\l  Ixfectiox  of  the  Prostate. 


Dr.  Geo.  Knowles  Swinburne  asserts  that  non-venereal  prosta- 
titis is  quite  common,  and  states  that  he  has  seen  a  large  number 
of  men  who  have  never  suffered  previously  from  gonorrhea.  He 
points,  however,  to  another  much  more  numerous  class  of  chronic 
prostatitis  which  followed  an  attack  of  gonorrhea,  but  in 
which  the  gonococci  haye  disappeared  and  have  become  replaced 
by  other  micro-organisms  as,  e.  g.,  the  colon  bacillus,  the  staphy- 
lococcus and.  last,  but  not  least,  the  streptococcus  which  will  so 
often  be  found  the  most  rebellious  to  treatment.  As  these  germs 
reach  the  prostate  probably  through  the  blood  stream,  it  is  easy 
to  explain  why  they  might  follow  a  gonorrheal  prostatitis  after 
that  disease  had  prepared  a  weakened  organ  for  their  reception. 
The  writer  believes  that  in  no  small  number  of  these  cases  those 
germs  had  already  found  a  lodgment  in  that  organ  before  a  gon- 
orrheal attack,  remaining  in  abeyance  during  that  attack  and  re- 
turning after  the  violence  of  the  gonorrheal  attack  had  subsided. 
— Medical  Critic  and  Guide. 


X.\iL  Puncture  Wounds  of  the  Foot. 


W.  Irving,  in  a  series  of  100  cases  of  this  injury  treated  during 
1916  at  Norton  Company  Hospital,  Worchester,  Mass.,  observed 
excellent  results  from  the  method  recommended  by  Dr.  W.  G. 
Hudson  of  the  DuPont  Company.  The  technic  is  as  follows :  The 
foot  is  thoroughly  cleansed  with  very  hot  water  and  soap,  dried, 
and  an  area  about  two  inches  square  around  the  puncture  wound 
is  thoroughly  washed  with  alcohol.  The  sole  of  the  foot  is  then 
painted  over  with  commercial  gasolene,  and  after  this  has  evap- 
orated one  or  two  coats  of  tincture  of  iodin  are  applied  in  and 
around  the  wound.  A  sterile  probe  is  gently  passed  to  the  full 
depth  of  the  wound,  and  after  it  fills  the  entire  tract  the  needle 


232     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

of  a  hypodermic,  filled  with  10  cc.  of  tincture  of  iodin.  is  gently 
inserted,  following  the  probe  as  a  guide  and  hugging  it  closely, 
down  to  the  bottom  of  the  wound.  The  iodin  is  now  injected  very 
slowly  and  allowed  to  run  oUt  along  the  probe  until  the  operator 
feels  certain  that  the  entire  wound  tract  has  been  thoroughly 
washed  out,  the  probe  and  needle  being  then  withdrawn.  A  dry 
sterile  dressing  is  then  applied.  If  the  puncture  wound  is  very 
deep  the  man  is  instructed  not  to  work  for  the  remainder  of  the 
day,  but  many  resumed  work  at  once.  Patients  are  advised  to 
return  in  twenty-four  hours,  even  though  they  are  having  no 
trouble.  According  to  Clark's  experience,  nail  puncture  wounds 
of  the  sole  of  the  foot,  when  caused  by  clean  nails  projecting 
from  a  board,  as  occurring  in  the  building  trade  and  general  con- 
struction, seldom  become  infected  if  properly  treated.  Tetanus 
does  not  develop  except  possibly  in  very  rare  instances. — Inter- 
national Journal  of  Surgery. 


Ether-Chloroform  Mixtures. 


W.  J.  McCardie  {Brit.  Med.  Jonr  )  April  21,  experimented  with 
various  mixtures  to  avoid  the  irritating  effects  of  ether,  soldiers 
being  especially  to  be  considered  on  account  of  exposure  result- 
ing in  pharyngitis,  and  excessive  smoking ;  and,  on  the  other  hand, 
the  depressing  effects  of  chloroform.  The  mixtures  used  varied 
from  four  parts  of  ether  to  one  of  chloroform  up  to  32  of  ether 
to  1  of  chloroform  (Note  the  influence  of  the  apothecary's  sys- 
system)  and  he  found  the  happy  mean  to  be  16  of  ether  to  1  of 
chloroform.  He  gives  1-6  gr.  (1  e.g.)  of  morphine  and  1-100 
(about  2-3  m.g.)  of  atropine  before  the  general  anesthetic. — 
Buffalo  Medical  Journal. 


The  Carrel  Method  of  Wound  Steriliz.\tion. 


William  O'Neil  Sherman  (Surg.  Gynec.  and  Obstet.,  March, 
1917),  presents  the  following  summary  of  his  views  on  the  Carrel 
method:     1.    Infection  can  be  aborted  if  the  treatment  is  begun 


EXTRACTS  FROM  JOURNALS  233 

within  the  first  twenty-four  hours.  2.  Suppuration,  when  well 
established,  can  be  controlled  if  the  focus  can  be  reached.  3. 
The  success  of  the  treatment  is  dependent  upon  the  perfection  of 
the  Carrel  technic  and  the  acceptance  of  all  the  details.  4.  The 
effect  of  Dakin's  solution  is  entirely  local ;  there  being  no  danger 
of  toxemia  from  absorption,  regardless  of  the  amount  used.  5. 
Carrel's  technic,  using  Dakin's  solution,  is  a  specific  against  in- 
fection of  wounds.  6.  Deaver's  dictum :  "He  who  drains  well, 
does  surgery  well,"  must  be  revised  to  "He  who  does  Carrel  well, 
does  surgery  well." — International  Journal  of  Surgery. 


Appendicitis  -\'ersus  Ectopic  Gestatiox. 


Appendicitis. 

1.  No  signs  or  symptoms  of  pregnancy. 

2.  Pain,  nausea,  vomiting  and  fever. 

3.  Tenderness  and  rigidity  high  up. 

4.  Leucocytosis  usual,  and  increases  from  hour  to  hour. 

5.  Patient  flushed  and  excited.  At  the  very  beginning  there 
may  have  been  a  little  dizziness. 

6.  Uterus  and  adnexa  normal. 

7.  Feel  a  tumor  high  up  in  the  pelvis. 

8.  No  uterine  symptoms. 

9.  Abderhalden  test  usually  negative. 

Ectopic  Gestation. 

1.  Present. 

2.  Pain  worse,  vomiting  less,  fever  absent  or  less. 

3.  Tenderness  and  rigidity  much  less  and  low  down. 

4.  Leucocytosis  equivocal.  The  blood  count  shows  increase  of 
the  polynuclears  and  mononuclears  and  the  basophiles  with  the 
signs  of  secondary  anemia.    Low  hemoglobin. 

5.  Pale  and  faint  or  apathetic. 

6.  The  characteristic  findings. 

7.  Tumor  low  in  the  pelvis. 

8.  Menstruation  atypical  and  discharge  of  decidua. 

9.  Abderhalden  test  usually  positive. — Medical  Rez'iew  of  Re- 
viexi's. 


234      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

MEDICAL 


Abortive  Treatment  of  Typhoid  Fever. 


Maiite  of  Alorocco  writes  on  this  subject,  and  first  states  that 
at  present  we  have  vaccines  to  prevent  the  disease,  but  as  yet  no 
real  abortive  remedy.  He  beheves,  however,  that  we  are  to  have 
one  in  the  intravenous  injection  of  certain  vaccines.  By  subcu- 
taneous injections  alone  the  finds  are  conflicting,  while  of  seven 
men  who  have  used  the  intravenous  route  all  are  agreed  as  to  the 
benefits  obtained — in  fact,  the  conclusions  are  absolutely  in  har- 
mony. The  only  American  mentioned  in  this  connection  is  Fred- 
eric Gay.  However,  to  offset  the  striking  abortion  of  the  disease 
in  certain  cases  is  the  violent  general  reaction  which  is  in  contrast 
with  the  slow  course  of  the  disease  proper,  and  may  end  in  col- 
lapse and  death.  In  other  words,  the  collateral  results  kill  the  idea 
of  the  treatment.  Is  this  reaction  controllable?  Much  or  all  de- 
pends on  the  dose  and  how  can  one  so  dose  a  vaccine  as  to  make 
it  safe?  There  is  hardly  any  margin  between  a  therapeutic  and 
a  toxic  dose.  If  the  amount  injected  is  too  small  we  get  neither 
action  nor  reaction.  There  is  clearly  a  marked  personal  equation. 
And  how  are  we  to  be  sure  that  this  curative  action  is  truly  spe- 
cific? A  specific  action  need  not  be  instantaneous — in  fact,  we 
know  that  more  or  less  delay  may  be  inevitable  in  known  specific 
medication.  The  sudden,  violent  reaction  is  rather  anaphylac- 
toid. The  author  has  therefore  sought  to  use  some  relatively 
harmless  animal  protein,  and  selected  a  nontoxic  saprophyte  which 
he  describes  accurately  but  does  not  identify.  He  made  an  emul- 
sion, which,  tested  in  animals  by  hypodermic  and  intravenous 
routes,  and  parenterally  was  found  to  be  free  from  toxic  effects. 
With  such  an  emulsion  he  treated  22  cases  of  typhoid  by  the 
intravenovis  method  (100  to  500  millions).  One  patient  only  was 
lost,  and  he  died  of  purulent  peritonitis,  following  perforative 
cholecystitis.  The  injections  were  made  in  the  morning,  and  in 
19  cases  there  was  defervescence  to  normal  or  subnormal,  irre- 
spective of  the  stage  of  the  disease.  After  this  act  of  deferves- 
cence the  temperature  in  many  cases  went  up  slowly,  and  several 


EXTRACTS  FROM  JOURNALS  235 

days  elapsed  before  it  reached  the  normal  high  point,  at  whicli 
juncture  a  second  injection  produced  a  permanent  defervescence. 
According-  to  the  accompanying  curves,  it  is  seen  that  in  one  case 
an  injection  (the  second)  caused  permanent  defervescence  on  the 
14th  day.  In  a  second  case  an  injection  on  the  10th  day,  with 
temperature  at  45.5°  C,  was  followed  by  a  gradual  deferves- 
cence which  was  complete  on  the  15th  day.  In  a  third  case  an  in- 
jection on  the  8th  day  caused  complete  defervescence.  The  tem- 
perature slowly  ascended,  and  from  the  loth  to  the  22d  day  of  the 
disease  never  went  over  39°  C.  A  second  injection  was  followed 
by  permanent  defervescence.  In  a  fourth  case  an  injection  on  the 
15th  day  was  followed  by  sudden  permanent  defervescence.  From 
these  few  cases  it  appears  that  an  injection  about  the  15th  day 
gives  the  best  or  most  ideal  result.  With  tlie  temperature  fall 
there  was  invariably  a  general  improvement.  The  rationale  of 
the  efficacy  of  foreign  protein  in  typhoid  is  obscure. — Medical 
Record. 


Addison's  Disease  in  Girl  of  13. 


The  rarity  of  Addison's  disease  in  young  subjects  gives  interest 
to  the  follow'ing  case : 

A  girl,  aged  13  years,  was  admitted  to  hospital.  She  was  the 
only  child  of  a  healthy  mother,  but  her  father  had  died  of  phthisis 
eight  years  previously.  She  had  been  apparently  healthy  till  about 
seven  weeks  before  admission,  when  she  bathed  in  a  river  during 
menstrual  period.  Menstruation  ceased,  a  rigor  followed,  and 
since  that  time  her  strength  had  gradually  failed.  The  skin  of 
the  whole  body  was  of  a  deep  bronze  color  resembling  that  of  a 
Hindoo.  The  face  had  a  peculiar  livid  color,  the  lips  were  very 
dark,  and  the  nipples  and  their  areolae  were  absolutely  black.  Other 
parts  of  the  body  showed  irregular  darker  patches.  The  pigmen- 
tation had  gradually  appeared  but  was  of  recent  date.  The  pa- 
tient complained  of  extreme  weakness  which  prevented  her  from 
assuming  the  erect  or  even  the  sitting  posture.  She  complained 
of  want  of  appetite  and  repeated   spontaneous   vomiting.     The 


236      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

pulse  was  rapid,  small  and  almost  imperceptible  at  the  wrist,  while 
the  lowering-  of  arterial  tension  was  evident.  There  were  no  pul- 
monary symptoms  and  she  slept  well  and  replied  intelligently  to 
questions.  On  admission  the  temperature  was  normal,  but  after 
a  week  it  rose  g^radually  to  100  degrees,  falling  to  normal  in  the 
morning.  During  the  day  preceding  death  (a  fortnight  after  ad- 
mission) it  remained  about  99  degrees,  continuing  at  this  level 
till  the  evening  of  the  following  day,  when  it  rapidly  rose  to  102.5 
immediately  before  death,  which  occurred  suddenly. 

She  was  treated  without  apparent  benefit  by  adrenalin  chloride 
in  doses  of  five  drops  twice  daily,  the  amount  being  increased  later 
to  seven,  and  ultimately  to  ten  drops. 

The  necropsy  showed  general  adhesion  of  the  pleurae  to  the 
chest  wall,  evidently  of  old  standing,  but  no  tubercles  were  seen 
in  the  lungs,  either  on  the  surface  or  on  section.  The  bronchial 
glands  were  intact  and,  contrary  to  rule,  there  was  no  tuberculosis 
of  the  mediastinal  glands.  The  right  suprarenal  capsule  was 
much  enlarged  nodular  and  softened.  On  section  a  caseo-purulent 
fluid  escaped,  and  it  was  impossible  to  distinguish  any  normal  tis- 
sues. The  kidney  of  the  same  side  showed  several  yellowish  tu- 
bercles. The  left  suprarenal  was  enlarged,  but  less  so  than  the 
right.  It  contained  numerous  yellow  tuberculous  granulations, 
but  there  was  no  suppuration.  The  left  kidney  also  presented 
some  scattered  tubercles. 

In  spite  of  the  youth  of  the  patient  the  case  is  typical  both  in 
clinical  course  and  postmortem  findings,  though  the  former  was 
short  and  rapid  and  the  latter  so  advanced  as  to  be  incompatible 
with  life. — The  Medical  Reviezv. 


Scabies. 

Among  the  cases  shown  by  Hartzell  in  a  skin  clinic  at  the  Uni- 
versity of  Pennsylvania  was  an  example  of  scabies.  While  scab- 
ies is  a  common  condition  it  often  goes  unrecog^iized  and  still 
more  often  is  imperfectly  treated.     Scabies  and  pediculosis  are 


EXTRACTS  FROM  JOURNALS  237 

the  only  two  itching  diseases  that  may  be  "caught."  Small  family 
epidemics  are  of  frequent  occurrence. 

Hartzell  points  out,  in  the  International  Clinics  for  June,  that 
the  diagnosis  is  to  be  made  from  the  fact  that  the  disease  is  con- 
tagious and  that  it  shows  a  predelection  for  certain  regions. 

In  very  young  children  the  palms  and  soles  are  often  affected. 
In  adults  the  sides  of  the  fingers,  the  flexures  of  the  wrists,  the 
anterior  axillary  folds,  the  breasts  in  women  and  the  shaft  of  the 
penis  in  men.  An  itching  desire  situated  in  these  regions  is  al- 
most certain  to  be  scabies.  Close  examination  will  show  a  few 
small,  dotted,  sinuous  lines  or  burrows  which  are  absolutely  path- 
ognomonic of  scabies. 

Ten  or  twelve  per  cent  sulphuric  ointment  is  an  efficient  remedy, 
but  is  too  irritating  for  infants  and  young  children.  Hartzell  rec- 
ommends for  the  latter  equal  parts  of  styrax  and  olive  oil,  or  one 
or  two  drams  of  balsam  of  Peru  to  the  ounce  of  vaseline.  Which- 
ever remedy  is  employed  it  should  be  rubbed  in  from  the  neck  to 
the  end  of  the  toes  and  fingers  on  three  or  four  successive  nights. 
This  should  be  followed  by  a  bath  and  then  wait  for  three  or  four 
days  to  see  whether  the  treatment  has  been  successful  and  to  avoid 
producing  a  dermatitis.  If  successful  the  treatment  is  repeated. 
All  members  of  the  family  must  be  treated. 


Errors  in  Diagnosis — A  Case  and  Its  Lesson. 

Charles  W.  Hitchcock  of  Detroit,  in  the  April  Journal  of  the 
Michigan  State  Medical  Society,  reports  the  case  of  a  colored  man, 
aged  27,  teamster,  whose  color  made  impossible  any  accurate  ob- 
servations of  the  skin ;  he  was  admitted  to  hospital  unconscious. 

His  friends  and  he,  also,  in  later  clear  moments,  attributed 
all  of  his  ills  to  a  blow  received  on  the  head  ten  days  prior  to  ad- 
mission.    There  was  a  positive  Widal  reaction. 

Family  and  personal  histories  were  negative..  There  seemed 
to  be  slight  left  iliac  tenderness.  There  was  some  cervical  rigid- 
ity, the  cremasterics  were  absent;  the  arm  reflexes  were  present 
and  normal ;  the  patellar  and  Achilles  jerks  were  present   and 


238     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

normal ;  there  was  no  clonus,  Gordon,  Oppenheim  or  Babinski  re- 
flex present.  There  was  well-marked  bilateral  Kernig-  sign.  Later 
a  clonus  was  present  in  both  ankles.  The  spinal  fluid  contained 
1800  red  cells.  Wassermann  was  negative.  There  was  a  leuco- 
cytosis. 

Two  hemorrhages,  doubtless  from  the  bowels,  occurred  two  or 
three  days  before  death.  They  were  not  carefully  investigated 
and  superficially  attributed  to  a  skin  traumatism. 

Basal  fracture  and  also  infectious  meningitis  were  diagnosed. 
The  Widal  was  lost  sight  of.  The  autopsy  showed  ulcers  in  all 
the  lymph  follicles  of  the  colon,  and  several  of  the  lower  Peyer's 
patches.  The  man  died  of  typhoid.  The  positive  laborator}'^  find- 
ings were  ignored,  and  efforts  were  needlessly  made  to  correlate 
nervous  symptoms  with  the  history  of  trauma. — Medical  Revieiv 
of  Reznews. 


New  Method  of  Auscultatory  Percussion  of  the  Chest. 


Instead  of  employing  the  usual  method  of  determining  con- 
tinuity of  any  area,  of  the  same  anatomic  and  pathologic  nature, 
by  noting  the  different  intensity  when  the  stethoscope  and  per- 
cussing finger  (or  as  in  the  editor's  modification,  a  tuning  fork, 
electric  buzzer,  etc.)  or  both  over  the  same  area  or  not,  the  au- 
thor places  the  stethoscope  over  the  upper  part  of  the  gladiolus 
of  the  sternum,  or  over  the  upper  spinous  processes  and  finds  that 
a  consolidated  area  transmits  a  higher  pitched  percussion  sound 
to  the  stethoscope.  He  also  combines  the  location  of  stethoscope 
and  percussor  by  using  a  double  diaphragm  stethoscope  and  per- 
cussing over  the  outer  diaphragm.  This  latter  method,  we  would 
suppose  could  be  used  in  locating  organs  generally. 


Rheum.\tism  and  Focal  Infection. 


J.  W.  Shuman  remarks  that  there  would  be  extremely  few  diag- 
noses of  "rheumatism"  made  today  if  a  careful  and  painstaking 
search  was  made   for  the  focus  of  infection  and  that  infective 


EXTRACTS  FROM  JOURNALS  239 

process  removed.  On  the  other  hand,  he  thinks  that  focal  infec- 
tion is  fast  becoming  a  fad  on  account  of  which  healthy  teeth  and 
tonsils  are  wantonly  sacrificed,  abdomens  are  needlessly  opened 
and  empirical  medication  (both  the  internal  and  squirting  kind) 
persisted  in.  The  reason  is,  not  sometimes  but  always,  faulty 
technic  on  the  part  of  the  diagnostician — snap-shot  diagnostic 
work.  Let  us  correct  this  by  as  careful  and  conscientious  work 
upon  the  patient  as  can  possibly  be  performed.  —  International 
Jonrnal  of  Surgery. 


Uncontrollable  Hiccup  Arrested  by  the  Oculo- 
CARDic  Reflex. 


The  young  man  was  completely  exhausted  by  the  incessant  hic- 
cup which  had  tormented  him  for  over  twenty-four  hours.  Bro- 
mids  gave  no  relief  and  a  dose  of  morphine  only  a  brief  respite. 
A  seidlitz  powder  caused  much  discomfort  but  did  not  arrest  the 
spasms  of  the  diaphragm  as  hoped.  Flexing  the  thighs  on  the 
abdomen  to  force  up  the  viscera,  massage,  and  rhythmic  traction 
of  the  tongue  also  proved  futile.  But  the  hiccup  stopped  at  once 
when  the  eyeballs  were  compressed  as  for  the  oculocardiac  reflex. 
The  radial  pulse  grew  slow,  the  hiccup  stopped,  and  the  exhausted 
man  dropped  to  sleep  at  once.  A  return  of  the  hiccup  next  day 
was  aborted  by  the  same  procedure.  It  also  proved  effectual  in 
a  case  of  hiccup  from  purulent  pleurisy. — The  Journal  of  the 
Am.  Med.  Asso. 


Acupuncture  Vaccination  Method. 


According  to  Dr.  H.  W.  Hill  acupuncture  vaccination  is  thus 
performed :  The  arm  is  washed  with  soap  and  water,  then  with 
alcohol  and  finally  with  ether.  A  small  drop  of  vaccine  is  depos- 
ited on  the  clean  surface.  The  vaccinator's  hand  is  closed  on  the 
arm  from  behind  so  as  to  draw  the  skin  tight  in  front,  and  a  sew- 
ing needle  point,  held  slanting  nearly  parallel  with  the  arm,  is 
pressed  against  the  skin  through  the  drop  of  vaccine.     Then  it  is 


240      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

that  that  one-thousandth  inch  of  the  point  sticks  through  the  up- 
per layer  of  the  skin,  carrying  the  vaccine  with  it.  The  needle  is 
instantly  withdrawn,  and  similar  punctures  are  made  beside  each 
other  until  a  dozen  punctures  are  made  in  the  space  of  one- 
sixteenth  square  inch  or  less.  With  a  bit  of  gauze  the  surface 
vaccine  is  removed.  Three  sets  of  punctures  are  advised  at  the 
angles  of  a  triangle,  each  side  of  which  is  1  inch.  A  strip  of 
gauze  may  be  pinned  to  the  inside  of  the  shirt  sleeve ;  no  other 
dressing  should  be  used.  In  persons  who  are  still  protected  by  a 
former  vaccination  or  by  having  had  smallpox,  the  punctured  sur- 
face will  redden,  swell  slightly  and  become  somewhat  itchy  for  a 
day  or  two  immediately  following  the  puncture.  This  is  the  ana- 
phylactic reaction.  In  persons  not  so  protected,  the  puncture  spot 
will  redden  and  swell  in  four  or  five  days,  and  a  smooth,  pearly 
button  about  the  size  of  a  large  pea  will  arise,  which  in  about  ten 
days  will  separate,  leaving  a  small  round  scar. — TJic  Journal  of 
the  American  Medical  Association. 


OliSTETRICAL 


Relation  of  the  Glands  of  Internal  Secretion  to  the 
Female  Pelvic  Organs. 


Dr.  Cecil  W.  Vest  expresses  the  opinion  that  definite  conditions 
associated  with  the  female  pelvic  organs,  are  indicative  of  an  ab- 
normal condition  of  some  of  the  glands  of  internal  secretion : 
that  hypophysis,  thyroid  and  ovary,  are  inter-related  in  their  func- 
tions; that  gland  therapy  is  of  value  in  cases  of  lactation,  atrophy 
of  the  uterus,  amenorrhea,  and  at  the  menopause.  The  writer 
observed  that  the  breasts  respond  sympathetically  to  change  in 
the  pelvic  organs  when  there  is  disturbance  in  the  internal  secre- 
tion of  the  latter;  they  are  often  painful,  and  in  certain  cases  of 
amenorrhea,  upon  the  ingestion  of  luteum  extract,  they  secrete 
an  opaque,  watery  fluid.  From  his  observation  the  writer  reports 
the  case  of  a  woman,  26  years  of  age,  who  had  not  menstruated 
for  a  year  and  a  half  after  she  had  been  confined  eighteen  months 


EXTRACTS  FROM  JOURNALS  241 

previously  and  suckled  her  baby  for  twelve  months.  She  was 
given  the  corpus  luteum  tablets,  5  grains  each,  twice  daily  for  six 
months.  About  ten  days  after  this  treatment  was  started,  the 
patient  began  having  a  profuse  flow  from  the  breasts.  This  con- 
dition persisted  for  five  months,  when  the  breast  flow  lessened, 
and  a  clotted  menstrual  flow  appeared,  which  has  continued  regu- 
larly and  normally  since  for  fourteen  months.  Following  the 
return  of  the  menses,  the  patient  felt  much  better  and  gained  17 
pounds  in  weight.  In  another  case  of  amenorrhea,  the  patient. 
aged  29,  began  menstruating  at  14;  when  22  her  menses  ceased 
until  about  one  year  ago,-after  she  had  been  taking  ovarian  ex- 
tract, 5  grains  twice  daily,  for  six  months.  The  writer  cautions 
against  being  too  eager  to  look  for  quick  results  in  cases  of  a 
long-standing  condition. — The  Medical  Critic  and  Guide. 


Opium  in  Peritonitis. 


Crile  strongly  endorses  the  use  of  opium  in  this  condition.  He 
bases  this  opinion  upon  the  results  of  clinical  experience  and  the 
fact  that  peritonitis  is  an  acute  infection,  that  death  is  due  to  ex- 
haustion following  the  expenditure  of  energy  in  the  struggle  of 
combatting  the  infection  ;  the  destructive  effects  of  resulting  acid 
byproducts ;  diminished  intake  of  nourishment  and  insufficient 
sleep.  Crile  lays  stress  upon  this  latter  factor,  because  in  peri- 
tonitis there  is  severe  pain,  while  in  the  acute  types  of  the  disease 
sleep  is  rare  and  disturbed.  He  therefore  advises,  for  the  purpose 
of  diminishing  the  absorption  of  toxins,  and  promoting  drainage, 
an  operation  under  nitrous  oxide  and  local  anesthesia  combined, 
with  the  patient  in  the  Fowler  position,  followed  by  physiological 
rest  to  the  intestine.  To  promote  rest,  he  advises  the  free  use  of 
opium,  emphasizing  the  point  that  the  dose  be  graduated  by  its 
effect  upon  the  respiratory  rate  and  not  by  weight  in  grains,  and 
properly  pushed  until  the  respirations  are  materially  reduced  in 
number.  Crile  declares  that  laboratory  findings  have  demon- 
strated that  this  effect  of  opium  protects  the  brain,  the  adrenals 
and  the  liver  against  the  damacfins:  effects  of  the  toxins.     It  also 


242      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERV 

diminishes  the  need  of  food,  which  in  turn  diminishes  metaboUsm. 
— Pacific  Medical  Journal. 


Vaginal  Plug  in  Antepartum  Hemorrhage. 


To  plug  efficiently,  Tweedly  says,  the  left  hand  should  be  passed 
into  the  vagina,  the  palmar  surface  directed  toward  the  hollow  of 
the  sacrum,  while  the  finger  tips  lie  behind  the  cervix.  Small 
pieces  of  cottonwool,  squeezed  out  of  dilute  compound  solution 
of  cresol  and  each  the  size  of  the  thumb  knuckle,'  are  then  taken 
and  inserted  by  means  of  the  right  hand  round  the  cervix.  The 
fingers  of  the  left  hand  are  kept  busy  squeezing  the  pellets  into  a 
compact  mass  and  forcing  the  spaces  between  them  to  permit  the 
insertion  of  still  another  plug.  This  process  is  continued  in  a  sys- 
tematic manner  from  above  downward  till  the  vulva  fs  reached 
and  the  vagina  can  hold  no  more.  A  T-bandage  is  applied  to  keep 
the  plug  in  position,  and  an  abdominal  binder  is  fastened  tightly 
from  above  downward  to  press  the  side  walls  of  the  uterus  against 
the  vaginal  dam,  and  thus  completes  the  operation.  A  plug  so 
applied  will  cause  immediate  cessation  of  hemorrhage,  and  when 
it  is  removed  after  the  lapse  of  hours  so  much  blood  only  will  be 
found  as  can  be  accounted  for  by  the  flow  that  took  place  during 
the  operation. — The  Journal  of  the  Am.  Medical  Asso. 


Pituitary  Extract  in  Obstetrics. 


Jimenez  describes  a  few  maternity  cases  in  which  he  used  pit- 
uitary extract,  and  relates  his  impressions  as  to  the  availability  of 
this  treatment.  He  declares  roundly  that  it  should  never  be  used 
with  a  normal  delivery.  Watchful  waiting  is  the  science  of  the 
obstetrician,  active  in  its  passiveness.  He  quotes  that  attempts 
to  hasten  labor  with  pituitary  extract  are  "useful  only  for  the  ac- 
coucheur and  possibly  also  for  gynecologic  specialists  later."  Also 
that  pituitary  treatment  is  never  required  in  a  normal  childbirth 
with  a  normal  woman.  In  one  case  he  was  summoned  to  a  w^oman 
who  had  been  in  labor  several  hours.     All  seemed  to  be  normal 


EXTRACTS  FROM  JOURNALS  243 

and  he  wished  to  leave  as  he  had  other  important  duties.  The 
family  would  not  consent  to  his  departure,  and  to  hasten  matters 
he  gave  pituitary  extract.  Delivery  occurred  at  once,  but  the 
deeply  asphyxiated  child  required  an  hour  and  a  half  of  active 
measures  before  he  could  safely  leave  it.  If  the  mother  had  had 
hemorrhage  or  other  complication  requiring  attention,  he  could 
not  have  saved  the  child.  In  conclusion,  he  lists  nine  formal  con- 
traindications against  the  use  of  pituitary  extract  in  obstetrics : 
It  should  never  be  given  when  there  is  the  slightest  fear  of  rup- 
ture of  the  uterus  or  signs  that  the  fetus  is  already  suffering.  It 
is  also  irrational  with  shoulder  presentation  and  in  most  cases  of 
pelvic  presentation.  It  is  also  contraindicated  in  elderly  primi- 
parse  with  rigid  perineum.  He  has  seen  in  such  cases  that  even 
two  or  three  injections  failed  to  induce  any  effect,  while,  on  the 
other  hand,  the  extract  is  very  dangerous  under  these  conditions 
for  the  fetus  and  for  the  maternal  soft  parts.  It  is  also  contra- 
indicated  before  the  cervix  is  fully  dilated ;  the  cervix  may  be  torn 
off  completely  if  not  fully  dilated.  Secondary  inertia  is  also  a 
contraindication,  when  the  uterus  has  wasted  its  contractile  energy 
against  some  obstacle  which  it  has  been  unable  to  overcome,  as 
with  contracted  pelvis,  tumor,  rigid  cervix,  etc.  If  the  obstacle 
is  unsurmountable,  giving  pituitary  extract  may  entail  the  rupture 
of  the  uterus  or  the  action  of  the  extract  may  lead  to  increased 
inertia,  or  the  head  may  be  finally  expelled  but  with  the  applica- 
tion of  such  force  that  brain  or  meningeal  hemorrhage  soon  prove 
fatal. — The  Journal  of  the  American  Medical  Association. 


244      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


iElittnrml 


PUBLISHER'S  NOTICE— The  Journal  is  published  in  monthly  numbers  of 
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All  communications  for  the  Journal,  books  for  review,  exchanges,  etc., 
should  be  addressed  to  the  Editor. 


The  Treatment  of  Cancer. 


We  believe  that  each  year  the  medical  profession  feels  more 
hopeful  in  regard  to  the  cure  of  cancer.  This  attitude  is  due  to 
the  fact  that  the  end  results  are  more  favorable.  Cases  come  to 
operation  before  the  disease  has  become  hopelessly  disseminated ; 
operators  do  radical  work,  knowing  by  sad  experience  that  an  in- 
complete operation  only  serves  to  distribute  malignant  cells  into 
tissues  previously  healthy.  Education  of  the  layman,  especially 
the  upper  classes,  has  had  a  good  effect,  though  in  internal  can- 
cers we  can  not  hope  for  much  from  education,  except  insofar  as 
it  will  teach  the  importance  of  regular  semiannual  consultation 
with  the  family  physician. 

The  modern  treatment  of  cancer  is  not  always  the  knife.  Each 
case  must  be  treated  according  to  its  individual  characteristics, 
and  the  treatment  can  be  scientifically  carried  out  in  any  of  the 
following  ways,  either  alone  or  in  combination : 

1.  Surgical. 

2.  X-rays. 

3.  Radium. 

4.  Chemicals. 

5.  Cautery. 

6.  Narcotics. 

At  the  present  time  few  cases  are  purely  surgical.  Most  car- 
cinomata  should  be  treated  before  and  after  operation  with  the 


EDITORIALS  245 

X-ray  or  radium,  since  we  know  that  both  these  agents  devitalize 
and  even  destroy  embryonic  cells.  In  carcinoma  of  the  breast,  for 
instance,  a  preoperative  radiation  of  the  mammary  gland  and  the 
axillary  space  tends  to  kill  any  cancerous  cells  which  might  be 
disseminated  during  operation ;  it  is  even  more  likely  to  devitalize 
these  cells  so  that  mitosis  and  propagation  will  not  occur  in  other 
healthier  parts  of  the  body.  Postoperative  X-ray  treatment  is  in- 
dicated in  order  to  destroy  any  cancerous  cells  left  after  opera- 
tion. 

The  effect  of  radium  and  the  Roentgen  ray  are  almost  identical 
if  used  by  those  experienced  in  their  use.  Superficial  cancers 
often  rapidly  disappear  when  treated  by  either  of  these  agents, 
and  occasionally  they  have  a  marvelous  effect  on  deep-seated 
growths.  We  have  seen  several  cases  where  large  intra-abdomi- 
nal growths  of  known  malignancy  have  disappeared  as  if  by  magic 
cifter  one  or  two  X-ray  treatments.  We  have  also  seen  epith- 
eliomata  of  the  face,  tongue  and  tonsils  clear  up  under  radium 
treatment,  and  have  examined  several  cases  of  cancerous  prostates 
in  which  radium  had  a  very  wonderful  effect  inasmuch  as  all  the 
usual  characteristics  of  cancer  of  this  gland  had  disappeared  and 
the  patients  had  gained  in  health  and  strength. 

Doctors  Hugh  Young  of  Baltimore  and  Barringer  of  New 
York  City  have  obtained  good  results  in  bladder  carcinomata 
with  encapsulated  radium.  We  have  been  fortunate  in  having  had 
an  opportunity  to  examine  several  of  Doctor  Barringer's  cases 
during  and  after  treatment. 

When  one  speaks  of  using  cauterizing  chemicals,  it  immediately 
calls  to  mind  the  many  quack  medicines  on  the  market,  but  chem- 
ical cauterants  are  used  at  the  General  Memorial  Hospital  in  New 
York  City,  which  is  now  devoted  to  cancer  research.  Of  course 
these  chemicals  are  used  by  an  expert  only  in  selected  cases  and 
usually  the  first  treatment  is  carried  out  under  anesthesia. 

Nothing  could  be  more  efficient  than  heat  in  the  destruction  of 
malignant  neoplasms  were  its  action  easy  to  control.  At  present, 
by  using  the  water-cooled  speculum  of  Percy,  cancers  of  the  cer- 
vix uteri  are  thoroughly  cauterized  without  injury  to  the  adjacent 
tissues,  as  a  preliminary  step  in  radical  pan-hysterectomy. 


246     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Heat,  however,  in  the  form  of  the  high  frequency  electric  spark 
has  proven  so  valuable  as  to  revolutionize  the  treatment  of  benign 
vesical  papillomata.  While  not  malignant,  they  tend  to  become 
malignant  more  than  any  other  benign  growth  and  to  treat  them 
while  still  benign  might  be  compared  to  operating  on  early  can- 
cers in  other  parts  of  the  body.  Furthermore,  suprapubic  opera- 
tions for  even  benign  vesical  papillomata  have  never  been  satisfac- 
tory since  implantation  papillomatosis  of  the  bladder  often  oc- 
curred even  when  the  growths  were  microscopically  benign. 

It  is  hardly  necessary  to  mention  the  narcotic  treatment  of  can- 
cer, except  to  point  out  that  were  it  not  for  the  pain-destroying 
properties  of  narcotics,  many  more  cancers  would  come  under 
treatment  before  inoperable  than  is  now  the  case.  Narcotics  are 
here  a  curse  as  well  as  a  blessing. 

With  all  our  therapeutic  armamentarium — and  the  above  brief 
citation  does  not  exhaust  it — the  cancer  mortality  is  woefully 
high,  and  our  best  hope  will  be  realized  when  something  definite 
is  learned  of  the  cause.  Our  present  ideas  in  this  respect  are  so 
chaotic  that  it  behooves  even  the  most  humble  practitioner  to  try 
to  fathom  this  secret  by  following  up  and  working  out  any  ideas 
he  may  entertain  as  to  the  ultimate  cause. — W.  T.  B. 


The  Medical  Profession  of  America  Must  Supply  Its 
Quota  of  Doctors  for  the  Army. 


In  round  numbers,  there  are  about  150,000  physicians  listed  in 
our  medical  directories.  Deducting  from  this  number  50,000 
names  of  those  who  are  not  in  practice  or  are  physically  incompe- 
tent, there  are  100,000  doctors  that  should  be  available.  Of  this 
number  the  Surgeon  General's  Office  requires  20,000,  or  one- 
fifth  of  the  active  practitioners,  as  officers  in  the  Medical  Reserve 
Corps  of  the  United  States  Army. 

The  unfounded  and  possibly  maliciously  circulated  reports  of 
the  casualties  among  the  medical  profession  in  the  armies  abroad 
have  deterred  many  from  applying  for  commissions.     In  reality 


EDITORIALS  247 

the  number  killed  on  the  entire  Western  front  from  the  beginning 
of  the  war  to  June  27.  1917.  a  matter  of  three  years,  was  195. 

The  lowest  commission  offered  a  doctor  is  First  Lieutenant, 
which  draws  in  pay  $2,000  a  year ;  Captains  receive  S2,400  and 
Majors  $3,000.  The  cost  of  equipment  is  about  $150  to  $175.  ac- 
cording to  the  desires  of  the  individual.  As  in  civil  life,  some  of 
us  are  satisfied  with  a  $25  suit  of  clothes  while  others  pay  $50, 
and  this  applies  to  a  medical  officer  in  purchasing  his  outfit  in  the 
way  of  uniforms,  blankets,  etc. 

The  individual  outlay  when  once  in  the  service  is  principally 
your  expenditure  for  food,  or  mess  as  it  is  called  in  military  cir- 
cles, and  this  will  average  about  $25.00  a  month,  or  about  $300 
a  year,  meaning  that  a  First  Lieutenant  should  have,  at  the  end  of 
the  year,  or  to  send  home  to  his  family  or  bank,  about  $1,700,  a 
Captain  about  $2,000  and  a  Major  at  least  $2,500. 

While  this  information  is  of  interest  to  those  contemplating  ap- 
plying for  commissions  in  the  Medical  Reserve  Corps,  the  fact 
remains  that  in  America  we  have  more  than  a  sufficient  number 
of  doctors  to  adequately  supply  the  demand  of  the  Surgeon  Gen- 
eral's  office  without  hardship  to  the  civilian  population. 

The  need  of  doctors  is  not  alone  for  the  mobile  army,  but  also 
in  concentration  camps,  evacuation  hospitals,  base  hospitals  and 
on  transports.  It  is  of  decided  advantage  to  volunteer  your  ser- 
vices and  receive  the  benefit  of  the  very  necessary  training"  ac- 
corded physicians  in  medical  training  camps.  It  is  a  safe  assump- 
tion that  for  those  who  receive  such  training  and  show  their  apti- 
tude for  the  service,  advancement  will  be  rapid. 

Applications  for  commissions  in  the  ^^ledical  Reserve  Corps 
will  be  found  printed  in  medical  journals  or  will  be  sent  to  you 
by  your  local  examining  board  or  by  the  editor  of  this  paper.  Ap- 
ply for  your  commission  iiozv.     Your  country  needs  you. 


Liberty  Bonds  Preferred  Stock. 


Likening  the  United  States  to  a  great  corporation  with  more 
than  a  hundred  million  stockholders  and  with  capital  stock  and 


248      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

resources  of  more  than  two  hundred  fifty  bilHons  of  dollars,  and 
an  annual  income  of  fifty  billions  of  dollars,  each  American  citizen 
is  a  stockholder  in  this  great  corporation.  Even  those  whose  only 
assets  are  their  earning  capacity  own  shares  in  our  public  domain 
and  property  and  are  working  on  a  profit  sharing  basis  with  a 
vote  and  a  voice  in  the  management  of  the  corporation  and  with 
the  right  to  acquire  more  stock  at  any  time. 

A  Liberty  Loan  Bond  may  be  likened  to  a  share  of  preferred 
stock  in  this  gigantic  corporation.  Like  preferred  stock  in  other 
corporations  it  may  not  return,  at  times,  so  large  a  dividend  as 
common  stock,  but  the  dividend  from  it  is  certain  and  sure.  It  is 
stock  that  pays  3^  per  cent  dividend  but  the  stock  and  dividend 
can  not  be  taxed  and  while  crop  failures  may  decrease  the  farm- 
er's dividend  from  his  land  some  years  to  less  than  nothing,  and 
various  causes  may  lessen  or  destroy  dividends  from  all  other 
sorts  of  property,  the  dividend  from  the  Liberty  Loan  Bond  is 
certain  and  sure,  subject  to  no  failure  or  diminution. 

The  owner  of  a  Liberty  Loan  Bond  holds  written  tangible  evi- 
dence of  being  a  preferred  stockholder  in  the  United  States,  the 
greatest,  the  most  glorious,  the  most  honorable  and  the  most  suc- 
cessful corporation  in  the  world.  He  holds  the  certificate  of  be- 
ing a  citizen  willing  to  support  his  government  and  to  lend  money 
to  his  country  when  it  needs  it  and  calls  for  it. 

There  is  honor  in  being  the  owner  of  a  Liberty  Loan  Bond  as 
well  as  profit. 


A  Time  To  S.we. 


There  is  only  one  thing  certain  about  the  financial  and  com- 
mercial conditions  that  peace  is  going  to  bring  and  that  is  their 
uncertainty.  It  may  be  that  an  era  of  great  prosperity  may  be 
upon  us ;  it  may  be  an  era  of  stagnation ;  it  may  be  an  era  of  the 
severest  competition  we  have  ever  experienced. 

It  involves  a  paradox,  but  in  this  present  time  of  comparative 
commercial  peace,  for  the  great  war  has  largely  stopped  for  a 
time  the  struggle  among  nations  for  foreign  commerce,  it  is  a 


EDITORIALS  249 

wise  thing  to  prepare  for  the  economic  war  that  will  succeed  the 
present  world-wide  war. 

It  is  well  for  every  American  citizen  to  lay  aside  in  some  abso- 
lutely safe  security  something  for  that  day  that  is  coming.  If  it 
be  great  prosperity  one  will  be  able  to  take  advantage  of  it.  If 
it  be  stagnation  one  will  be  better  able  to  withstand  it. 

Xo  better  provision  could  be  made  for  the  future  than  an  in- 
vestment in  Liberty  Loan  Bonds.  They  are  absolutely  safe  and 
no  possible  condition  can  destroy  their  value;  exempt  from  all 
taxation  except  estate  or  inheritance  taxes  the  income  from  them 
can  not  be  lessened;  with  a  market  everywhere  in  the  United 
States  and,  as  competent  financial  authorities  assert,  a  market  in 
every  commercial  center  in  the  world  when  peace  comes,  they 
will  be  readily  convertible  into  cash.  They  possess  all  of  the  ele- 
ments that  would  attract  a  sound  investing  mind  in  times  of  un- 
certainty. 

More  than  that  an  American  citizen  investing  in  Liberty  Loan 
Bonds  is  investing  in  victory,  for  the  proceeds  of  the  Liberty  Loan 
Bonds  are  to  win  the  war  and  bring  peace  in  Europe  and  peace 
and  safety  to  the  rest  of  the  world. 


Patriotism  Will  Tell. 


Much  has  been  said  and  written  unofificially  about  the  possibility 
of  conscripting  the  medical  profession  to  supply  the  desired  quota 
of  physicians  for  the  immense  army  that  our  government  is  now 
raising. 

Physicians  are  as  essential  to  the  success  of  an  army  as  muni- 
tions, and  if  our  troops  are  to  be  the  deciding  factor  in  the  terrible 
conflict  now  raging  in  foreign  lands,  the  Surgeon  General's  of- 
fice must  be  supplied  with  a  sufficient  number  of  doctors  in  the 
Medical  Reserve  Corps  to  take  care  of  the  full  complement  of 
troops  in  the  field,  on  transports,  in  Evacuation  Hospitals  and 
Base  Hospitals,  in  Concentration  Camps,  etc. 

While  it  is  no  reflection  upon  any  man's  honor  to  be  conscripted, 
at  the  same  time  we  feel  sure  that  a  sufficient  number  of  doctors 


250      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

will  volunteer  their  services  at  an  early  date,  which  means  con- 
siderable to  the  individual  so  applying. 

It  is  reasonable  to  suppose  that  those  who  volunteer  early  and 
receive  the  benefit  of  instruction  in  a  Medical  Training  Camp, 
will  be  the  ones  who  will  receive  advanced  commissions.  The 
lowest  commissions  offered  to  a  doctor  is  that  of  First  Lieutenant, 
and  it  draws  the  pay  of  $2000  a  year ;  Captains  receive  $24(X)  and 
Majors  $3000. 

The  principal  expense  to  a  medical  officer  will  be  his  mess 
charges  or  food,  and  this  should  not  be  over  $25  a  month  or  $300 
a  year  in  round  figures. 

Whatever  may  be  the  pay,  the  fact  remains  that  the  Surgeon 
General  must  have  at  least  20,000  physicians  in  the  Medical  Re- 
serve Corps  to  supply  the  present  demand,  and  we  feel  that  the 
patriotism  of  the  medical  profession  will  be  the  stimulus  that  will 
induce  a  sufficient  number  of  doctors  to  offer  their  services  vol- 
untarily. 

Blanks  for  commissions  in  the  Medical  Reserve  Corps  are  now 
appearing  in  medical  journals  or  will  be  supplied  you  by  the  Board 
in  your  own  State.  If  you  do  not  know  the  location  of  this  Board, 
the  Editor  of  this  paper  will  be  glad  to  inform  you  or  send  you  a 
blank  upon  request. 


National  Board  of  Medical  Examiners. 


To  the  Editor  NashinUe  Journal  of  Medicine  and  Surgery: 

My  Dear  Doctor — The  National  Board  of  Medical  Exami- 
ners held  its  second  examination  in  Washington,  D.  C,  June  13 
to  21.  There  were  twenty- four  qualified  candidates,  twelve  of 
whom  appeared  for  examination,  the  others  having  been  ordered 
into  active  duty  between  the  time  of  their  application  and  the 
date  of  the  examination.  Of  the  twelve  who  took  the  examina- 
tion nine  passed. 

The  next  examination  will  be  held  in  Chicago,  October  10  to  18. 
The  regular  corps  of  Army  and  Navy  may  be  entered  by  success- 


EDITORIALS  261 

fill  candidates,  without  further  professional  examination,  provid- 
ing they  meet  the  adaptability  and  physical  requirements. 

There  will  also  be  an  examination  in  New  York  City  in  the 
early  part  of  December.  We  will  appreciate  notices  of  these 
facts  in  your  journal.  Very  truly  yours, 

J.  S.  Rodman,  M.D..  Secy. 


A  Heritage. 


What  more  honorable  heritage  can  you  leave  your  children  than 
a  Liberty  Loan  Bond?  It_will  give  them  the  right  in  after  years 
to  refer  with  pride  to  you  as  being  one  of  those  Americans  who, 
at  their  country's  call,  honorably,  willingly  and  patriotically  sup- 
ported their  government  in  this  great  war  and  lent  of  their  wealth, 
their  savings  or  their  earnings  to  help  bring  victory  to  our  armies 
and  a  triumphant  end  to  this  war  for  freedom  and  humanity. 


Washington,  July  27,  1917. 
Dear  Doctor: 

The  Bureau  of  the  Census  is  planning  to  prepare  and  publish 
a  monograph  on  the  Mortality  from  Tuberculosis  covering  the 
calendar  year  1918.  To  make  this  work  of  greater  value  an  en- 
deavor is  being  made  to  obtain  the  cooperation  of  all  physicians 
to  the  extent  of  carefully  recording  or  supervising  the  statements 
of  occupations  upon  the  death  certificates  during  that  year.  Cir- 
cular letters  to  this  effect  have  been  sent  to  all  the  physicians  in 
the  United  States  and  a  few  words  along  the  same  line  in  your 
Journal  would,  I  feel  sure,  be  of  great  benefit  and  would  be  deeply 
appreciated  by  this  Bureau. 

The  following  extracts  from  the  circular  letter  might  well  be 
published  in  your  Journal  to  serve  as  the  text  for  any  additional 
comment : 

More  accurate  and  definite  statements  of  the  occupations 
of  decedents  should  be  written  upon  death  certificates.  Until 
this  is  done  mortality  statistics  by  occupations  will  continue 
to  be  unsatisfactory. 


252     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

The  Bureau  of  the  Census  is  planning  for  the  near  future 
a  monograph  on  tuberculosis.  How  much  more  valuable 
this  monograph  will  be  if  it  is  possible  to  show  accurately 
the  occupations  of  decedents. 

As  a  physician  you  appreciate  the  importance  of  such  sta- 
tistics. As  a  physician  you  are  by  education  better  qualified 
than  the  ordinary  informant  to  understand  a  proper  state- 
ment   of  occupation. 

Will  you  not,  therefore,  take  pains  to  see  that  the  occu- 
pation items  upon  each  one  of  your  death  certificates  are 
properly  supplied : 

Thanking  you  for  your  cooperation,  I  am. 
Very  truly  yours, 

Sam  L.  Rogers,  Director. 


REVIEWS  AND  BOOK  NOTICES  253 


a^tohifi  attb  Innk  NnttrrB 


The  Causes  of  Tuberculosis — Together  with  Some  Account  of  the  Prev- 
alence and  Distribution  of  the  Disease.  By  Louis  Corbit,  M.D.,  F.  R. 
C.  S..  University  Lecturer  in  Pathology,  Cambridge.  Cambridge.  At 
the  University  Press.    1917. 

We  are  indebted  to  the  obliging  publishers  for  a  copy  of  this 
classical  work.  This  book  is  one  of  a  series  of  volumes  entitled 
the  Cambridge  Public  Health  Series  to  be  published  from  time  to 
time  by  the  Cambridge  University  Press  on  subjects  relating  to 
the  public  health.  This  one  of  the  series  under  the  editorship  of 
G.  S.  Graham-Smith.  AI.D.,  and  J.  E.  Purvis,  M.A.,  treats  fully 
and  exhaustively  of  the  causes  of  tuberculosis.  In  line  with  the 
world-wide  campaign  for  the  lessening  of  the  mortality  from  the 
Great  White  Plague  it  is  addressed  to  those  who  are  interested 
in  the  stamping  out  of  tuberculosis.  It  is  a  notable  fact  that  the 
ravages  of  the  disease  have  been  very  materially  lessened  in  the 
last  few  years  and  with  the  efforts  that  are  being  put  forth  we 
can  hope  that  in  the  not  distant  future  the  world  may  become  rid 
of  this  incubus. 

The  tubercle  bacillus  and  its  varieties  are  fully  dealt  with,  treat- 
ing of  their  distribtition,  cultural  characters  and  virulence. 

The  book  is  addressed  to  all  interested  in  stamping  out  the  dis- 
ease and  therefore  should  reach  a  class  of  readers  w^ho  are  not 
physicians,  such  as  health  committees  and  workers  in  hygiene  and, 
on  that  account,  is  free  from  technical  language.  The  relations 
of  animal  and  human  tuberculosis  are  fully  presented.  Every 
phase  of  the  subject  has  been  treated  in  a  masterful  manner  and 
the  book  is  really  a  gold  mine  of  the  question  in  book  form. 


264     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


Chemical  Food  is  a  mixture  of  Phosphoric  Acid  and  Phosphates,  the 
value  of  which  physicians  seem  to  have  lost  sight  of  to  some  extent  in 
the  past  few  j^ears.  The  Robinson-Pettet  Company,  incorporated,  to 
whose  advertisement  (in  this  issue)  we  refer  our  readers,  have  placed 
upon  the  market  a  much  improved  form  of  this  compound,  "Robinson's 
Phosphoric  Elixir."  Its  superiority  consists  in  its  uniform  composi- 
tion and  high  degree  of  palatability. 


A  HOT  WEATHER  SUGGESTION. 


One  of  the  difficulties  attending  the  employment  of  cod  liver  oil  in 
hot  weather  is  its  proneness  to  cause  unpleasant  gastric  disturbances 
resulting  finally  in  the  patient's  inability  to  continue  with  the  oil.  The 
best  way  to  obviate  this  difficulty  is  to  use  Cord.  Ext.  Ol.  Morrhuae 
Comp.  (Hagee).  This  preparation  is  so  palatable  and  acceptable  that 
it  does  not  give  rise  to  the  disagreeable  effects  of  the  plain  oil  or  an 
emulsion,  and  may  be  used  as  freely  during  hot  weather  as  during  any 
other  time.  Furthermore,  Cord.  Ext.  Ol.  Morrhuae  Comp.  (Hagee)  is 
just  as  effective  therapeutically,  containing,  as  it  does,  every  property 
of  the  oil  that  is  of  advantage. 


DEFICIENT  GLANDULAR  ACTIVITY. 


With  hundreds  of  physicians  it  is  a  routine  practice  to  depend  upon 
lODIA  (Battle)  in  glandular  sluggishness.  A  well  balanced  formula, 
lODIA  (Battle)  possesses  unusual  therapeutic  potency,  and  has  dis- 
tinctive merit  in  overcoming  inactivity  of  the  glandular  apparatus.  A 
marked  advantage  of  lODIA  (Battle)  is  its  palatability  and  the  toler- 
ance of  the  stomach  to  it.  This  feature  makes  it  of  particular  value 
in  children  who  are  oftentimes  afflicted  with  a  chronic  glandular  en- 
largement which  is  a  pointed  indication  for  lODIA  (Battle).  It  may  be 
pushed  with  a  minimum  of  untoward  effects. 


ADVANTAGES  OF  PASADYNE  AS  A  NERVE  SEDATIVE. 


The  advantages  offered  .by  PASADYNE  (Daniel)  in  those  conditions 
demanding  sedation  lie  in  its  marked  therapeutic  potency  and  its  free- 
dom from  untoward  after-effects.  And  when  it  is  remembered  that 
most  of  the  regularly  employed  agents  for  the  purpose  give  rise  to  im- 
mediate or  remote  evil  effects,  such  as  gastric  disturbances  or  habitual 
addition,  the  actual  value  of  these  advantages  becomes  all  the  more 
apparent.     PASADYNE    (Daniel)    simply   a   concentrated  tincture   of 


PUBLISHERS'  DEPARTMENT  2SS 

passiflora  incarnata.  shows  its  calming  power  in  all  states  marked  by 
hypercerebration  or  exalted  fimction  of  the  nervous  system.  It  may 
be  used  with  a  feeling  of  confidence  in  women  and  children. 


FOR  THE  CLOGGED  LIVER. 


When  the  liver  does  not  act  as  it  should,  the  zest  of  life  departs,  and 
the  saying  that  "life  and  living  depend  upon  the  liver,"  although  some- 
what facetious,  contains  more  than  a  modicum  of  truth.  An  engorged 
liver,  of  course,  signifies  that  the  organ  requires  active  stimulation, 
especially  when  the  condition  is  attended  by  manifestations  of  auto- 
toxemia.  If  any  one  fact  has  been  more  definitely  established  than 
another  it  is  that  such  stimulation  should  not  be  brought  about  by  the 
use  of  drastic  cathartics,  for  if  so,  the  remedy  is  frequently  worse  than 
the  disease  in  its  sinister  effects.  What  is  particularly  needed  is  a 
means  of  stimulation  which  will  satisfactorily  increase  the  functional 
activity  of  the  liver,  without  setting  up  catharsis  or  over  activity  of 
the  bowels. 

The  above  needs  are  well  met  by  Chionia,  an  exceedingly  effective 
and  reliable  preparation  of  Chionanthus  Virginica.  This  well  known 
product  exerts  a  distinctly  specific  action  on  the  liver  and  is  probably 
one  of  the  most  efficient  remedies  at  the  command  of  the  physician  for 
stimulating  the  hepatic  function.  Administered  in  regular  and  appro- 
priate dosage  it  increases  the  flow  of  bile,  relieves  congestion  of  the 
biliary  passages,  promotes  digestion  and  although  it  cleanses  the  in- 
testinal canal  It  accomplishes  this  without  purging  or  griping. 

Chionia,  therefore,  has  proven  of  extraordinary  value  in  the  treat- 
ment of  all  functional  disorders  of  the  liver,  especially  those  grouped 
under  the  value  term  "biliousness"  and  characterized  by  digestive  dis- 
turbances, jaundice,  constipation  or  diarrhea,  headaches,  and  auto- 
toxic  symptoms  generally.  The  prompt  and  decided  results  that  uni- 
formly follow  the  use  of  Chionia  furnish  convincing  evidence  of  the 
utility  of  this  trustworthy  product. 


HEART  TROUBLES. 


Numerous  persons,  especially  those  of  middle  age  and  past  and  who 
live  sedentary  life,  suffer  from  worrying  heart  symptoms.  As  a  rule, 
no  organic  lesions  can  oe  detected  but  the  functional  disturbances 
which  are  generally  in  evidence,  are  a  source  of  constant  alarm.  Often- 
times, a  person's  life  is  made  a  burden  by  the  pain  and  other  sensa- 
tions which  affect  the  heart. 

Such  cases  give  the  physician  an  infinity  of  bother.  In  the  first  in- 
stance, the  patient's  manner  of  living  must  be  regulated,  appropriate 
diet  must  be  prescribed  and  excessive  indulgence  in  narcotics  or  stimu- 
lants must  be  interdicted. 

A  regimen  of  this  nature,  horwever,  while  essential  will  not  effect  a 
complete  cure.  A  therapeutic  remedy  which  will  give  tone  to  the  tired 
heart,  but  which  will  not  act  as  a  spur  is  needed.  The  heart  requires 
persuasion  instead  of  driving.    Cactina  Fillets  will  not  only  effect  this 


256     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

object  but  possess  the  great  advantage  over  the  majority  of  heart 
remedies — that  they  have  no  cumulative  action.  Consequently,  there 
is  no  safer  heart  tonic  known  than  Cactina  Fillets.  In  all  cases  of 
functional  heart  affections  their  use  is  strongly  indicated,  for  they  un- 
failingly bring  back  the  heart's  action  to  its  normal  rhythmical  ebb 
and  flow  and  the  patient's  fears  vanish  accordingly. 


THE  RATIONAL  TREATMENT  OF  ATONIC  DYSPEPSIA. 


Glandular  inactivity  of  laziness  is  probably  the  chief  cause  of  the 
various  manifestations  of  dyspepsia  and  indigestion.  In  the  stomach 
this  common  disorder  causes  the  usual  symptoms  of  pain,  fermentation 
and  distress,  which  it  is  not  necessary  to  discuss,  and  also  unques- 
tiona.bIy  contributes  to  the  development  of  gastrectasia  and  ptosis.  In 
fact,  it  is  surprising  how  many  cases  of  organic  disease  of  the  stomach 
results  from  the  commonest  dyspepsias  improperly  treated  or  not 
treated  at  all. 

In  such  cases  of  dyspepsia  and  atonic  indigestion,  in  which  the  glands 
of  the  stomach  are  not  doing  their  full  share  of  work,  and  the  muscular 
insufficiencies  which  eventually  result  are  in  the  making  instead  of 
giving  muscular  stimulants  line  strychnia,  one  should  try  to  promote 
the  work  of  the  glands  by  using  a  recognized  secernent  like  Seng.  This 
well-known  product  of  the  laboratories  of  the  Sultan  Drug  Company. 
St.  Louis,  Mo.,  is  a  remarkably  efficient  stimulant  to  the  gastric  glands. 
The  simplest  test  will  prove  its  value,  and  show  the  wisdom  of  aiding 
and  promoting  physiologic  functions  rather  than  to  supply  substitutes. 
The  usefulness  of  Seng  has  been  demonstrated  in  all  forms  of  atonic 
indigestion,  particularly  those  incidental  to  neurasthenia,  general  de- 
bility and  protracted  convalescence  from  fevers,  surgical  operations 
and  so  on. 


NASHVILLE  JOURNAL 


OF 


MEDICINE  AND    SURGERY 


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


Vot.  CXI.  SEPTEMBER,  1917.  No.  9 

Original  QlnmmuntrattonB 

EPILEPSY. 


BV  C.  L.  LEWIS,  JR.,  M.D.,  NASHVILLE,  TENN. 

Formerly  House  Surgeon  Bellevue  Hospital,  New  York  City. 


Mr.  President  and  Gentlemen  of  the  Academy: 

In  presenting  this  dissertation  upon  the  subject  of  the  evening, 
I  do  so  with  trepidation,  fully  recognizing  its  gravity,  and  the  fact 
that  many  more  worthy  than  myself  have  written  upon  this  sub- 
ject without  giving  us  true  insight  to  its  mysteries. 

The  loss  of  equilibrium  being  the  first  symptom  to  attract  at- 
tention, this  disease  was  known  to  the  early  writers  as  "the  falling 
sickness."  Since  that  time  the  term  has  been  applied  to  a  far 
wider  range  of  phenomena,  which  are  characterized  by,  1st,  Sud- 
den loss  of  consciousness  with  convulsions ;  2nd,  Sudden  loss  of 
consciousness  without  muscular  implication ;  3rd,  ^Muscular  con- 
vulsions without  loss  of  consciousness,  as  well  as  to  certain  men- 
tal phenomena. 

It  is  probable  this  disease  has  been  known  since  the  time  of 
Christ,  but  our  more  exact  knowledge  has  been  gained  largely 
within  the  last  twenty  years — due  to  our  more  exact  knowledge 
of  anatomy  and  the  functions  of  the  nervous  system.    The  prin- 


258     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

cipal  forms  assumed  by  epileptic  affections  are  as  follows:  1st, 
Grand  Mai,  2nd,  Petit  Mai ;  3rd,  Convulsions  without  loss  of  con- 
sciousness ;  4th,  Vertigo ;  5th,  Double  consciousness ;  6th  Hystero- 
epilepsy ;  7th,  Laryngeal  epilepsy ;  8th,  Procursive  epilepsy.  The 
so-called  layngeal  epilepsy,  or,  vertigo,  is  unquestionably  a  variety 
of  epilepsy.  It  consists  of  a  slight  loss  of  consciousness,  the  cause 
of  which  has  been  found  to  be  some  laryngeal,  tracheal  or  bron- 
chial affection,  such  as  laryngeal  tumor,  asthma,  etc.  Procursive 
epilepsy  consists  of  running  movements  forward,  but  otherwise 
presenting  the  usual  phenomena.  It  may  alternate  with  ordinary 
epilepsy,  precede  it  or  merge  into  it. 

I  knew  of  an  interesting  case  of  this  variety  at  the  East  Ten- 
nessee Asylum,  at  Knoxville,  Tenn.  It  was  that  of  a  boy  who 
invariably  put  his  hands  in  his  pockets,  and  whistling  with  all  his 
might,  ran  up  and  down  the  ward,  until,  with  a  wild  cry,  he  threw 
up  his  hands  and  fell  in  a  well-defined  fit.  Hystero-epilepsy  is  the 
name  given  to  an  odd  combination  of  epilepsy  and  hysteria.  Hys- 
tero-epilepsy rarely  begins  as  true  epilepsy,  but  generally  with 
tonic  convulsions,  followed  by  the  so-called  purposive  acts,  clown- 
ishness  or  absurd  acts  of  all  kinds ;  opisthotonos,  distended  abdo- 
men, cramps,  passionate  attitudes,  etc.  The  condition  of  double 
consciousness  occurs  after  the  attacks  of  grand  mal  and  petit  mal. 
Many  of  the  cases  that  figure  in  the  newspapers  of  people  wan- 
dering away  from  home  and  coming  to  themselves  afterward  in 
a  far  away  place  may  be  ascribed  to  this  form  or  condition  of  ep- 
ilepsy. Such  attacks  are  characterized  by  acts  on  the  part  of  the 
patient,  of  an  impulsive  annd  unnatural  character,  of  which  he  is 
unconscious.  They  simulate  in  some  cases  attacks  of  momentary 
insanity,  during  which  patients  will  often  wander  through  crowded 
thoroughfares,  commit  acts  of  immodesty  or  indecency,  uttering 
lewd  expressions  and  committing  acts  of  violence.  Some  sud- 
denly find  themselves  standing  or  sitting  in  unexpected  places,  as 
in  a  closet,  or  committing  some  act  of  which  they  had  no  will,  and 
often  no  motive  to  perform.  Kleptomania  may  be  attributed  to 
this  form  of  epilepsy.  In  some  cases  convulsive  movements  alone 
occur.    Gray  cites  a  case  who  would  not  carve  because  of  the  ten- 


ORIGINAL  COMMUNICATIONS  259 

dency  his  arms  had  to  fly  apart  and  whirl  carving  knife  and  fork 
in  eccentric  circles. 

We  find  a  sensation  of  vertigo  frequently  accompanies  epilepsy, 
and  are  found  quite  frequently  in  the  interval  between  the  attacks. 
Petit  mal  consists  of  a  loss  of  consciousness,  so  slight  that  it  seems 
often  like  absent-mindedness.  I  have  seen  patients  attacked 
whilst  in  the  act  of  drinking  a  cup  of  coffee,  stop  short  in  the  act, 
stare  in  a  dazed  condition,  and  then  resume  the  act  as  if  nothing 
occurred.  These  cases  vary  in  severity  from  the  mere  fibrillary 
twitching  of  a  muscle  to  those  cases  of  epilepsia  major,  into 
which  they  insensibly  metge.  In  many  of  these  attacks  there  are 
certain  sensations,  which  occur  previous  to  the  convulsive  move- 
ments. These  sensations,  which  are  called  "aurze,"  vary  in  kind 
and  degree.  They  have  been  described  to  me  as  a  hot  or  cold 
belt  of  constriction,  passing  upward  from  the  extremities,  the 
general  attack  supervening  when  the  aura  passes  into  the  cervical 
region  of  the  cord.  I  believe  this  sensation  to  be  a  vaso-motor 
wave,  causing  a  spasmodic  action  of  the  blood  vessels. 

It  would,  indeed,  be  superfluous  for  me  to  describe  an  ordinary 
epileptic  attack  before  this  learned  audience,  so  I  will  content  my- 
self by  directing  your  attention  to  those  more  obscure  cases  where- 
in, I  believe,  lie  the  open  sesame  to  a  more  thorough  knowledge  of 
this  truly  distressing  affection.  The  many  phases  which  this  dis- 
ease may  assume  (the  gradual  transition  from  the  mildest  forms 
to  that  of  epilepsia  major),  can  be  approached  in  comparison  only 
with  one  other  disease,  i.  e.,  that  of  insanity. 

Indeed,  gentlemen,  epilepsy  is  so  nearly  akin  to  insanity  that 
its  worse  forms  we  designate  as  ''epileptic  insanity."  I  have  been 
told  by  patients  that  during  an  attack  they  have  impulses  to  com- 
mit acts  of  all  kinds,  have  lascivious  thoughts  and  utter  lewd  ex- 
pressions. From  the  rythmical  twitching  of  an  eyelid  to  the  awful 
convulsive  seizure,  which  we  so  frequently  witness  on  our  streets, 
from  the  hysterical  laugh  to  the  foaming  mouth  and  gnashing 
teeth,  I  have  seen  men,  eminent  in  our  profession,  stand  by  help- 
less from  the  sense  of  our  little  knowledge  of  this  purely  nervous 
trouble.  There  has  been,  according  to  all  authorities  on  this  sub- 
ject, and  to  my  conviction,  more  flagrant  ignorance  shown  by  the 


260     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

medical  profession  toward  the  management  of  this  disease  than 
to  any  two  disease  we  come  in  contact  with.  The  marked  abuse 
of  bromides  in  this  affection  has  led  many  of  the  best  practition- 
ers to  abandon  its  use^  as  detrimental  to  the  patient.  With  those 
gentlemen  I  most  happily  concur.  I  do  not  think  it  rational  to 
substitute  brominism,  with  all  its  attendant  evils^  to  mask  the 
cause  and  defeat  the  treatment.  Find  the  cause  and  treat  your 
case  intelligently.  There  is  no  such  a  thing  as  "idiopathic  epi- 
lepsy." All  efifects  have  a  cause.  Epilepsy,  in  my  opinion,  is  due 
to  the  want  of  a  stable  equilibrium  of  the  circulation.  I  started 
to  say  "cerebral  circulation,''  but  I  think  facts  will  bear  me  out  in 
my  first  statement. 

I  have  looked  in  vain  in  some  of  our  latest  textbooks  for  a  state- 
ment of  the  bounding  heart,  the  full  and  incompressible  pulse,  the 
cold  extremities,  the  gastro-intestinal  disorder,  the  foetid  breath, 
the  coated  tongue,  and  many  other  symptoms  that  accompany  this 
disorder. 

The  trouble  is  that  many  of  our  best  writers  seem  to  think  of 
epilepsy  as  being  a  head  trouble,  pure  and  simple.  In  this  assump- 
tion they  are  greatly  mistaken.  Epilepsy  is  a  disturbance  of  the 
nervous  system,  to  a  great  extent  the  vaso-motor  system,  created 
by  the  reflex  action  of  a  peripheral  stimulus,  acting  on  a  perverted 
nervous  constitution.  ]\Iany  reflex  stimuli,  which  cause  epilepsy 
in  perverted  persons,  do  not  cause  serious  trouble  in  health,  and 
I  believe  right  here  is  the  gist  of  this  whole  matter.  This  per- 
version may  be  inherited  or  acquired  ,and  is  closely  related  to,  and 
may  alternate  with  chorea,  migraine,  various  neuralgias,  and  many 
other  nervous  affections.  In  enumerating  the  reflex  causation,  I 
shall  place  eyestrain  in  a  prominent  place.  There  is  no  doubt  in 
my  mind  but  that  the  influence  of  the  eye  upon  the  brain  and 
nervous  system  is  great,  and  that  a  disturbance  of  its  function 
may  cause  great  damage  to  the  cerebrum.  This  effect  is  well  ex- 
emplified in  hypnotism,  many  subjects  throwing  themselves  into 
a  hypnotic  trance  by  concentrating  their  eyesight  upon  some  bright 
object.  If  this  effect  can  be  obtained  from  simple  concentration, 
what  could  an  over-acting  eyestrain  produce  ?  In  the  same  way  I 
believe  epilepsy  can  be  produced  by  afferent  impulses  from  the 


ORIGINAL  COMMUNICATIONS  261 

five  special  senses— sight,  hearing,  smell,  taste  and  sensibility. 
An  ulcer  of  the  rectum,  fissure  of  the  anus,  stricture  of  the  ureth- 
ra, fractured  skull,  decayed  teeth,  injuries  to  nerve  trunks,  cere- 
bral tumors,  masturbation,  over-sexual  indulgence,  syphilis,  and 
many  other  causes  could  be  enumerated.  The  main  pathological 
changes  found  in  old  cases  are  secondary  to  a  series  of  circum- 
stances, which  has,  indeed,  created  a  new  nature — an  epileptic 
nature.  From  recent  cases  where  we  find  no  pathological  changes 
to  cases  of  long  standing,  where  we  find  evidences  of  chronic  men- 
ingitis, old  extravasations,  sacculated  blood  vessels,  sclerosis,  con- 
gestions, ansemia,  softeniiig,  tumors,  old  depressed  fractures  and 
many  other  changes  which  I  have  not  time  to  mention.  This  is, 
to  a  great  extent,  a  vaso-motor  disease.  Undoubtedly,  the  same 
system  that  controls  the  blood  pressure  has  an  important  place  in 
the  pathology  of  this  disease.  Drugs  that  control  the  blood  pres- 
sure the  best  are  the  most  valued  remedies  in  the  treatment. 

I  have,  with  the  unaided  use  of  ergotole,  controlled  mild  cases 
and  lessened  others.  In  other  words,  restored  a  stability  to  the 
circulation  which  had  been  lost,  and  thus  producing  that  calm, 
confidence  we  find  in  the  deep  and  powerful  undulations  of  a 
normal  pulse.  Thus  we  find  that  class  of  remedies  which  restore 
tone  to  the  circular  muscular  fibres  of  the  arterial  wall,  in  con- 
junction with  certain  cerebral  sedatives  to  allay  the  perverted 
irritability  of  the  motor  cells  of  the  cerebrum  and  spinal  cord, 
are  the  most  useful  remedies  in  controlling  the  convulsions.  I 
shall  sum  up,  in  a  few  words,  the  treatment  that  should  be  fol- 
lowed, in  accordance  with  the  views  I  have  expressed : 

1st.  See  that  all  possible  reflex  causes  have  been  attended  to. 
To  this  end,  all  the  special  senses  should  be  carefully  examined. 
These  are  the  afferent  avenues  by  which  the  brain  gains  knowl- 
edge of  the  outer  world,  and  are,  of  course,  the  chief  causes  of 
reflex  activity.  2nd.  Put  your  patient  on  a  rigid  diet  of  the  most 
digestible  articles  of  food.  These  patients  have  perverted  appe- 
tites, and  are  prone  to  overload  their  stomachs.  See  that  the  se- 
cretions are  well  regulated,  that  their  tongues  are  not  coated,  that 
their  breath  is  not  offensive,  but  sweet,  that  their  liver  is  not  tor- 
pid, that  their  skin  is  not  allowed  to  become  clogged,  but  that  it  is 


262     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

kept  soft  and  healthy  by  frequent  ablutions,  friction,  massage, 
electricity,  etc.  3rd.  Be  careful  with  your  moral  treatment.  These 
patients  are  inclined  to  be  willful,  arrogant,  peevish,  irritable, 
gloomy,  morose  and  perverse.  So  that  a  positive  firmness  must 
be  brought  to  bear  upon  them.  If  necessar>',  a  nurse  should  be 
provided  to  see  that  your  every  instruction  is  carried  out.  An 
out-door  life  should  be  prescribed  as  far  as  possible.  4th.  Occa- 
sional calomel  purges.  This  I  have  found  to  be  of  much  value. 
I  know  I  have  prevented  attacks  of  petit  mal  by  timely  doses  of 
calomel.  A  simple  combination  of  ergotole  10  min.,  tinct.  digi- 
taUs  7  min.,  and  chloral  7^^  grains,  I  have  found  to  be  the  most 
effectual  in  petit  mal.  In  one  case  of  seventeen  years  standing 
I  have  prevented  attacks  for  long  periods  and  lessened  severity 
by  occasional  doses  of  this  combination.  In  more  severe  cases  I 
put  my  patients  on  large  doses  of  ergotole,  extract  gelsemium 
fluid,  with  small  doses  of  chloral,  bromides  and  digitalis,  and  in 
some  cases  blood  letting. 

In  closing  this  paper  I  do  so  with  a  due  sense  of  the  gravity  of 
the  subject  under  discussion,  and  with  the  hope  that  others  may 
corroborate  my  views  upon  epilepsy. 

P.  S. — Credit  is  given  Dr.  Landon  Carter  Gray  for  the  classi- 
fied forms. 


SELECTED  ARTICLES  263 


^^brteb  ArtirUfi 


TREATMENT  OF  THE  VOMITING  OF  PREGNANCY 

WITH  OVARIAN  EXTRACT  AND  CORPUS 

LUTEUM. 


BY  P.   J.   CARTER,   M.D.,   NEW  ORLEANS. 


Without  going-  into  the  chemistry,  pathology,  and  physiology 
of  this  disease,  I  shall  attempt  to  give  only  the  treatment  that  has 
been  most  efficacous  in  my  hands.  We  know  that  vomiting  of 
pregnancy,  and  especially  the  pernicious  type,  is  a  most  common 
complication  of  the  parturient. 

It  is  most  unfortunate  that  our  present  knowledge  of  the  sub- 
ject is  so  limited  and  involves  so  many  questions.  Seeing  these 
poor  unfortunate  mothers,  fighting  with  death  from  constant  and 
long  continued  nausea,  that  leads  to  serious  results  from  inanition, 
with  the  constant  distress  it  occasions,  impresses  upon  us  the  fact, 
that  we  have  to  contend  with  a  serious  and  treacherous  disease. 

This  condition  may  make  its  appearance  during  any  stage  of 
pregnancy.  It  may  appear  a  few  weeks  after  conception,  and  con- 
tinue for  a  few  days,  or  it  may  continue  throughout  the  whole  of 
pregnancy.  It  may  make  its  first  appearance  during  the  latter 
half  of  pregnancy,  or  even  during  the  last  month.  I  have  had 
occasion  to  treat  two  such  cases  recently. 

One  of  our  foremost  writers,  in  dealing  with  this  subject,  says: 

"Functional  diseases  may  be  so  transient  as  to  cause  only  a 
temporary  inconvenience,  while  others  are  so  grave  as  to  endanger 
the  life  of  the  patient.  Very  often  the  vomiting  of  pregnancy  is 
due  purely  and  solely  to  local  causes  in  connection  with  the  gravid 
uterus,  be  it  a  mechanical  pressure,  a  displacement,  or  some  mor- 
bid condition  of  the  uterus.  Then  again  we  see  those  cases  in 
which  the  cause  is  simplex,  and  we  are  unable  to  define  it,  though 
it  may  be  said  to  be  due  partly  to  pressure,  partly  to  sympathetic 


264     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

irritation,  or  partly  to  nutritive  changes  produced  by  the  pregnant 
uterus." 

Whether  this  disease  has  its  initiation  in  the  reflex,  neurotic, 
or  toxic  variety,  the  treatment  I  shall  outline  is  the  same.  On 
account  of  the  lack  of  knowledge  as  to  the  causation  of  this  dis- 
ease, much  study  and  countless  remedies,  and  forms  of  treatment, 
have  been  suggested  for  its  relief.  Fisch,  in  1884,  reported  a 
case  of  the  severe  form  of  vomiting  of  pregnancy  cured  by  the 
use  of  thyroid  extract.  Seigmund  reports  a  case  cured  by  the 
evacuation  of  a  densely  packed  colon. 

To  continue  with  the  more  modern  forms  of  treatment,  Pinard 
used  eliminative  measures,  since  he  believed  that  intoxication  was 
responsible  for  the  tendency  of  pregnant  women  to  vomit.  Somers 
(Western  Medical  Review,  November,  1910)  treated  his  vomiting 
cases  by  the  Ochsner  treatment  for  appendicitis.  Martin,  of  Lon- 
don, used  gastric  lavage,  together  with  dieting  and  elimination. 

The  very  latest  method  of  treatment  before  the  use  of  ovarian 
extract  and  corpus  luteum  was  that  of  Fieux  and  Dantin.  They 
used  the  serum  of  healthy  pregnant  women  who  were  at  the  same 
state  of  pregnancy  as  the  afifected  ones,  giving  it  intramuscularly 
into  the  buttocks  in  varying  quantities,  depending  upon  the  grav- 
ity of  the  case.    Their  reports  have  been  very  encouraging. 

I  began  my  experiments  in  the  treatment  of  nausea  of  preg- 
nancy in  October,  1915.  It  was  through  the  cooperation  and  kind- 
ness of  Parke,  Davis  &  Co..  and  Lilly  &  Co.,  in  supplying  me  with 
enough  ovarian  extract  and  corpus  luteum  to  carry  out  my  experi- 
ments. I  had  never  heard  of  ovarian  extract  being  used  to  con- 
trol the  vomiting  of  pregnancy,  therefore  I  began  on  a  purely  ex- 
perimental basis.  At  the  Lying-in-  Hospital  of  New  York,  where 
I  had  the  pleasure  of  serving  as  house  surgeon  during  a  term  of 
1913-14,  I  saw  and  treated  quite  a  number  of  these  cases.  At  that 
time  we  only  knew  of  and  practiced  the  eliminative  measures  to 
control  the  vomiting,  just  as  we  did  in  our  eclamptic  cases.  Our 
results  were  not  very  encouraging. 

Since  October,  1915,  I  have  had  twenty  consecutive  cases.  I  re- 
port these  on  account  of  the  phenomenal  success  obtained.  Every 
case  responded  satisfactorily,  and  without  a  single  failure,  though 


SELECTED  ARTICLES  265 

in  a  few  cases  I  found  it  necessary  to  increase  the  dosage.  The 
duration  of  vomiting  after  beginning  the  treatment,  averaged 
from  one  day  to  two  weeks;  the  general  average  being  ten  days. 

To  give  an  idea  as  to  the  varying  quantity  of  the  drug  and  the 
duration  of  vomiting  after  medication,  the  following  case  reports 
are  given : 

Case  1 — Mrs.  H.,  age  22,  para  II.  In  her  first  pregnancy  had 
severe  nausea  and  vomiting.  At  that  time  she  was  six  weeks 
pregnant.  Abortion  performed.  A  second  pregnancy  followed 
three  months  later  with  the  same  distressing  symptoms.  Twelve 
doses  of  ovarian  extract^  five  grains  each,  were  given  three  times 
a  day,  at  the  end  of  which  time  the  condition  was  relieved  entirely. 
At  her  fourth  month,  she  began  to  vomit  again.  The  same  treat- 
ment was  again  given,  after  which  she  went  to  full  term  and 
was  delivered  without  any  recurrence  of  the  nausea. 

Case  2 — Mrs.  S.,  aged  23,  para  I.  Was  seen  by  me  in  her  sec- 
ond month.  Simple  nausea  every  morning  but  very  distressing. 
This  had  continued  two  weeks  before  I  saw  her.  Six  tablets  of 
ovarian  extract  were  given,  though  three  controlled  the  nausea 
completely.  She  is  now  eight  months  pregnant,  and  has  not  had 
the  least  discomfort  since  her  first  medication. 

Case  3 — Mrs.  F..  para  IV.  Three  and  one-half  months  preg- 
nant, former  pregnancies  normal,  no  nausea.  Vomiting  began  at 
six  weeks,  and  had  continued  daily  since.  Vomited  several  times 
a  day,  irrespective  of  meals.  She  was  extremely  emaciated,  coun- 
tenance pale,  skin  cold  and  clammy.  Temperature  100°,  pulse 
116.  She  was  given  eleven  tablets  of  ovarian  extract,  five  grains 
each,  over  a  period  of  thirty-six  hours,  at  the  end  of  which  time 
her  vomiting  was  completely  checked.  Fortunately  she  did  not 
vomit  the  medication. 

Case  4 — Mrs.  F.,  age  25,  para  II.  No  nausea  or  vomiting  with 
her  first  pregnancy.  When  first  seen  was  five  months  pregnant. 
Extremely  emaciated,  cold  and  clammy  skin.  Temperature  101, 
pulse  120.  Loss  of  weight  in  past  two  months  had  exceeded  20 
pounds,  and  her  vomiting  had  continued  since  the  second  month. 
The  drain  upon  the  body  had  been  so  severe  that  she  was  in  a 
delirious  state  most  of  the  time.  Stomach  rejected  everything. 
Glucose,  5  per  cent  solution  was  at  once  started.    Twelve  doses  of 


266     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

corpus  luteum  by  needle  was  given  over  a  period  of  24  Iwurs, 
making  the  injections  every  two  hours.  At  the  end  of  this  time 
she  was  a  great  deal  better,  and  could  retain  ovarian  extract  by 
mouth.  For  several  days  ovarian  extract  was  given  three  times 
a  day.  After  the  twelfth  injection  of  corpus  luteum  she  was  able 
to  retain  liquids  by  mouth.  In  two  weeks  she  was  on  a  solid  diet, 
and  there  was  complete  abeyance  of  all  nausea  and  vomiting. 

I  do  not  contend  that  ovarian  extract  or  corpus  luteum  will  cure 
every  case  of  vomiting  pregnancy,  but  it  will  largely  control  those 
of  the  toxic  type.  My  experience  with  Copeman's  method  and 
the  bimanual  replacement  of  a  displacement,  have  not  been  very 
encouraging.  I  have  attempted  to  correct  many  of  these  displace- 
ments, to  find  relief  only  by  the  administration  of  ovarian  extract. 

With  my  limited  experience  with  these  drugs,  I  give  the  ovarian 
extract  alone  where  there  is  not  incessant  vomiting,  and  the  pa- 
tient's stomach  will  tolerate  it.  The  ovarian  extract  seems  to  give 
the  quickest  relief,  and  the  patient  is  not  annoyed  by  the  repeated 
use  of  the  hypodermic  needle.  In  cases  of  a  more  serious  type,  in 
which  the  patient  vomits  everything,  then  we  rely  upon  our  corpus 
luteum  by  needle.  For  the  reason  that  patients  object  to  the  nee- 
dle, and  the  lengthened  time  (in  my  experience),  to  get  results 
with  the  corpus  luteum,  I  begin  my  ovarian  extract  as  soon  as  the 
stomach  will  tolerate  it.  Corpus  luteum  has  been  a  life  saver  in 
those  grave  cases,  in  which  vomiting  was  incessant,  and  should 
be  administered  as  long  as  the  patient  is  in  such  a  perilous  state. 

The  literature  upon  these  two  drugs  in  the  treatment  of  vomit- 
ing of  pregnancy  is  extremely  scarce,  so  much  so  that  barely  half 
a  dozen  papers  have  been  devoted  to  the  subject.  John  C.  Hirst, 
{Jour.  A.  M.  A.,  Vol.  LXVI,  No.  9)  gives  a  preliminary  report  of 
five  cases  with  80  per  cent  success.  In  these  cases  he  administered 
corpus  luteum  only  and  by  needle.  Later  on  he  was  able  to  add 
a  few  more  cases  to  his  experiments,  which  increased  his  percent- 
age to  84  per  cent.  The  smallest  dose  used  in  this  series  of  cases 
numbered  four;  the  largest  forty-two,  the  average  dose  was  11. 

From  these  statistics  we  should  be  convinced  of  the  virtue  of 
twenty  consecutive  cases  treated  successfully,  should  cause  every 
obstetrician  to  give  this  treatment  a  thorough  investigation  as  to 
its  therapeutic  value. — New  Orleans  Medical  Jaurnal. 


EXTRACTS  FROM  JOURNALS  267 


ExtrartB  from  ^amt  and  Jomgn  ioitrttalB 


SURGICAL 


Injuries  to  the  Pancreas  Following  Operations  on  the 
Right  Kidney. 


Hugh  H.  Young  and  J.  A.  C.  Colston  (James  Buchanan  Brady 
Urological  Institute,  John's  Hopkins  Hospital)  suggest  that  many 
cases  of  severe  postoperative  distention  may  be  due  to  injury  to 
the  pancreas  during  kidney  operations.  Such  injury  may  occur, 
as  is  shown  by  the  autopsy  on  one  case  described,  and  is  a  most 
serious  accident.  The  pancreas  extends  around  the  duodenum  to 
the  point  where  it  is  nearest  the  kidney,  and  at  this  point 
the  structures  are  fixed  so  that  they  can  not  recede  in  case  of  trau- 
ma. In  the  case  mentioned,  an  aberrant  artery  to  the  pole  of  the 
kidney  made  necessary  the  use  of  clamps  in  the  depths  of  the 
wound,  the  pancreatic  tissue  being  crushed.  The  authors  advised 
greatest  care  to  avoid  this  event. — Journal  of  Urology. 


Roentgenther.\py  in  Deep-Seated  Malignancy. 


James  T.  Case,  in  discussing  the  present  status  of  this  method, 
states  that  he  does  not  believe  in  submitting  operable  malignan- 
cies to  radiotherapy,  in  place  of  surgery.  The  use  of  the  roent- 
gen rays  and  radium,  at  least  for  the  present,  should  be  restricted 
to  pre-  and  post-operative  irradiation,  and  to  treatment  of  inop- 
erable malignancies.  Radiotherapy  does  destroy  cancer  cells. 
This  destruction  can  be  brought  about  without  serious  injury  to 
the  neighboring  normal  tissues.  The  destructive  effect  is  a  deep 
one,  both  for  radium  and  the  roentgen  rays.  The  roentgen  rays 
have  a  much  greater  intensity  and  penetration  than  is  usually  ap- 
preciated. The  ideal  method  is  to  employ  a  combination  of  ra- 
dium and  roentgentherapy  in  all  cases  of  tumors,  affecting  cavi- 


268     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

ties  of  the  body.  There  is  no  question  about  the  possibiUty  of 
effecting-  a  local  cure  of  cancer  in  the  human  body.  We  lose  our 
patients  in  the  end  because  of  inaccessible  metastases.  But  in  the 
way  of  palliation  of  suffering,  prolongation  of  useful  life  and,  in 
a  few  unexpected  cases,  clinical  cure  lasting  a  decade  or  longer, 
there  is  no  other  known  therapeutic  agency  that  can  equal  the 
results  of  radiotherapy. — International  Journal  of  Surgery. 


Local  Anesthesia  in  Sixty  Cases  of  Acute  and 
Chronic  Appendicitis. 


Joseph  Wiener  says  that  he  has  been  using  local  anesthesia  in 
more  and  more  acute  cases  of  appendicitis  and  thinks  that  peri- 
tonitis, far  from  contraindicating  performance  of  the  operation 
under  local  anesthesia  will  gradually  become  an  indication  for 
this  operation.  When  we  consider  that  the  system  is  already 
struggling  to  throw  off  a  peritoneal  infection,  and  that  the  or- 
gans of  excretion  are  doing  a  large  part  of  this  defensive  work, 
the  danger  of  handicaping  these  organs  still  further  is  apparent. 
Of  the  sixty  cases  which  furnish  the  basis  of  this  communication, 
forty-one  were  chronic  and  nineteen  were  acute.  The  acute  cases 
included  empyema  of  the  appendix,  gangrene,  large  abscess  of 
the  appendix  and  two  cases  of  well  marked  peritonitis.  Including 
both  the  acute  and  chronic  cases  the  average  time  of  operation 
was  twenty-two  minutes.  Postoperative  distention  was  strikingly 
absent  in  most  all  of  the  cases,  and  the  writer  considers  this  one 
of  the  great  advantages  of  local  anesthesia.  With  the  exception 
of  the  peritonitis  and  abscess  cases,  nausea  and  vomiting  were 
almost  uniformly  absent  in  these  cases.  The  average  stay  in  bed, 
including  both  acute  and  chronic  cases  was  a  little  less  than  seven 
days.  The  local  anesthetic  consists  of  the  following:  Three  quar- 
ters of  an  hour  before  operation  the  patient  receives  a  quarter  of 
a  grain  of  morphine  hypodermically.  Just  before  operation  this 
dose  is  usually  repeated,  unless  the  patient  appears  drowsy  from 
the  first  injection.  A  one  per  cent  solution  of  novocaine  to  an 
ounce  of  which  twenty  drops  of  1 : 1,000  solution  of  epinephrin 


EXTRACTS  FROM  JOURNALS  269 

have  been  added  is  used.  Tablets  of  novocaine  with  epinephrin 
are  a  great  convenience.  The  writer  dissolves  five  one-grain 
tablets  in  an  ounce  of  water  and  this  suffices  for  the  complete  op- 
eration. He  finds  the  post-operative  course  in  these  cases  in  strik- 
ing contrast  to  what  we  see  in  cases  that  have  had  ether.  A  few 
hours  after  the  operation  there  is  little  wound  pain,  which  is  easily 
controlled.  Peristalsis  is  usually  established  early.  Almost  all 
the  patients  have  been  able  to  take  and  retain  fluids  within  a  few 
hours  after  the  operation.  There  is  an  entire  absence  of  the  men- 
tal depression  so  common  after  ether.  The  writer  says  he  intends 
to  use  this  method  in  an  ^ver-increasing  number  of  cases,  and  be- 
lieves that  in  not  a  few  cases  it  will  actually  be  life-saving. — Med- 
ical Record. 


The  Replacemext  of  Morphine  in  Surgical  Practice, 
WITH  a  Report  of  110  Cases. 


In  the  Long  Island  Medical  Journal  for  May,  1917,  Schall  gives 
these  results  from  clinical  tests  on  pantopon : 

He  replaced  morphine  medication  in  the  surgical  wards  by  us- 
ing pantopon. 

The  sedative  eft'ect  of  pantopon  was  very  noticeably  greater  than 
that  of  its  morphine  equivalent.  Respiratory  and  cardiac  depres- 
sion were  far  less  marked  than  when  morphine  was  used. 

Postoperative  nausea  or  vomiting  and  constipation  were  very 
much  reduced  through  the  new  method  of  procedure. 

Intestinal  stasis  or  paralysis  and  anuria  were  not  observed  in 
a  single  case.  Patients  suffered  no  inconvenience  when  adminis- 
tration of  pantopon  was  discontinued. — The  Therapeutic  Gazette. 


Sarcoma  of  Eowel  in  a  Child. 


D.  K.,  age  5  years,  complained  of  more  or  less  pain  in  the  bowels 
for  five  or  six  weeks  previous  to  my  being  called  to  attend  her.  She 
was  treated  with  various  kinds  of  cathartics  during  this  time,  as 
it  was  also  noted  that  her  bowels    were  more  or  less  constipated. 


270     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

On  being  called,  I  was  told  that  the  child  had  had  no  movement  of 
the  bowels  for  five  days.  The  child  had  a  temperature  of  102  de- 
grees F,  pulse  140,  and  had  vomited  fecal  matter.  The  abdomen 
was  very  much  distended  and  painful  all  over. 

Diagnosis  of  obstruction  with  coexisting  peritonitis  was  made 
and  operation  advised,  which  was  consented  to.  The  same  even- 
ing, with  Dr.  F.  F.  Knorp,  the  abdomen  was  opened  and  a  tumor 
of  the  ileum  and  three  inches  on  either  side  was  resected  and  an 
end  to  end  anastomosis  made.  The  child  made  a  good  recovery 
and  at  the  present  time  is  feeling  better  than  at  any  time  for 
months  past  and  has  increased  in  weight. 

Pathologist's  report:  "Examination  of  sections  made  from 
specimen  shows  lymphosarcoma.' — Pacific  Medical  Journal. 


Projectile  in  the  Heart. 


Pezzi  calls  attention  to  a  case  recently  reported  by  Ascoli  in 
which  a  shrapnel  ball  entered  the  back  in  the  iliac  region  and  its 
course  was  traced  by  radioscopy  along  the  vena  cava  and  into  the 
right  auricle  where  it  seems  to  be  harmlessly  sojourning.  The 
symptoms  at  the  time  of  the  wound  and  while  the  projectile  was 
in  the  vein  were  quite  severe,  but  since  it  entered  the  heart  there 
has  been  no  appreciable  disturbance.  It  has  probably  become 
coated  with  fibrin,  and  as  it  is  tossed  about  in  the  blood  stream 
pouring  through  the  heart,  it  probably  gets  no  chance  to  come  in 
contact  with  the  walls  of  the  auricle,  and  the  retrograde  current 
as  the  valves  close  keeps  it  away  from  the  valves  likewise.  In  ten 
cases  on  record  of  a  projectile  in  the  heart,  an  attempt  was  made 
to  extract  the  projectile.  Four  of  the  patients  died,  but  the  oper- 
ation was  a  success  in  six  cases.  But  even  in  these  favorable  cases 
there  were  threatening  heart  and  pulmonary  disturbances.  Ascoli 
does  not  advise  any  operation  in  his  case  as  the  lungs  are  diseased 
and  the  general  health  poor.  The  case  confirms  the  prevailing 
physiologic  conceptions  as  to  the  mechanism  of  the  action  of  the 
atrioventricular  valves. — The  Journal  of  the  American  Medical 
Association. 


EXTRACTS  FROM  JOURNALS  271 

MEDICAL 


Simplified  Technic  for  Detection  of  Amebas. 


Ravaut  says  that  if  the  amebas  in  the  feces  have  still  any  vitality 
left,  they  can  be  started  up  to  move  about  by  heating  the  slide  as 
it  lies  in  the  microscope.  The  flame  of  a  match  or  a  small  tam- 
pon dipped  in  alcohol  and  held  under  the  slide  will  answer  the 
purpose,  or  with  a  dentist's  heated  rubber  bulb  a  jet  of  hot  air 
can  be  directed  on  the  under  side  of  the  slide.  The  cysts  can  be 
shown  up  best  by  impregnating  them  with  a  mixture  of  0.5  gm. 
iodin  and  1  gm.  potassium  iodid  in  50  gm.  distilled  water.  If 
feces  are  treated  with  a  5  per  cent  solution  of  liquor  formalde- 
hydi  the  cysts  keep  well  for  months.  He  puts  5  c.c.  of  this  solu- 
tion in  a  test  tube  with  a  lump  of  feces  about  the  size  of  a  pea. 
The  tube  is  plugged  with  non-absorbent  cotton,  and  it  is  shaken 
up  until  the  contents  are  well  mixed.  They  will  keep  then  for 
months  and  the  cysts  show  up  clearly. — The  Journal  of  the  Am- 
erican Medical  Association. 


Diet  ix  Tvphoid  and  Paratyphoid  Fevers. 


In  a  recent  work  on  typhoid  Vincent  and  Muratet  state  that  in 
France  milk  is  the  great  reliance  in  feeding  typhoid  and  para- 
typhoid patients.  The  milk  is  always  boiled  for  ten  minutes  at 
least,  giving  up  to  2  liters  with  at  least  2  liters  of  other  fluid.  The 
milk  can  be  given  hot  or  cold,  and  flavored  with  tea,  coffee,  brandy 
or  rum,  vanilla,  orange  flower  water,  or  a  drop  of  oil  of  anise  to 
a  cup  of  milk,  or  the  milk  can  be  made  acid  or  efferescent.  In 
case  of  absolute  intolerance  for  milk,  kefir  or  koumiss  may  be  sub- 
stituted, or  a  strained  vegetable  broth  or  gruel.  For  the  latter 
they  use  a  mixture  of  a  tablespoonful  each  of  barley,  wheat, 
crushed  corn  and  hulled  beans,  peas,  and  lentils,  boiled  for  three 
hours  in  3  liters  of  water,  salted  and  strained.  Every  hour  or  half 
hour  a  glass  or  half  glass  should  be  given  of  weak  tea,  cofifee, 
lemonade  with  or  without  wine,  or  weak  diuretic  decoctions  (dan- 


272     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERV 

delion,  licorice,  cherry  stems).  To  avoid  fermentation  these 
drinks  should  not  be  much  sweetened ;  lactose  can  be  used,  on  ac- 
count of  its  diuretic  action,  instead  of  sugar.  The  patient  should 
drink  often,  but  little  at  a  time  and  slowly.  Robin  gives,  in  addi- 
tion to  the  above,  a  liter  of  chicken  or  veal  broth  in  the  twenty- 
four  hours.  Chantecesse  prefers  to  give  two  or  three  tablespoon- 
fuls  of  meat  juice,  the  amount  that  can  be  squeezed  from  200  gm. 
of  chopped  meat.  The  first  solid  food  allowed  is  a  light  tapioca. — 
The  Journal  of  the  American  Medical  Association. 


Death  Following  the  Stixg  by  a  Wasp. 


Recently  death  occurred  to  an  engine  room  artificer  of  Ports- 
mouth, England,  who  had  been  stung  by  a  wasp  while  sleeping  on 
board  his  ship.  The  swelling  of  his  neck  was  so  great  that  he  had 
to  be  sent  to  the  Haslar  Hospital,  where  he  died  on  the  following 
day.  At  the  inquest,  Surgeon  Caldwell  ascribed  death  to  bacte- 
rial infection  caused  by  the  wasp's  sting.  The  deceased  was  a 
healthy  man,  hence  the  virulence  of  the  infection  must  have  been 
extreme.  A  verdict  of  accidental  death  was  rendered. — The 
Practical  Medicine. 


Gout  and  Infectious  Arthritis. 


In  two  clinical  lectures,  in  the  International  Clinics  for  June, 
Christian  considers  differential  points  between  gout  and  acute  and 
chronic  arthritis.    There  are  three  types  of  gout : 

First — Obvious  depositions  of  urates  in  the  bone  or  in  the  carti- 
lage, or  in  both. 

Second — In  which  that  does  not  occur,  but  in  which  there  are 
chronic  arthritic  changes,  with  exostoses  and  associated  atrophy 
of  the  cartilage,  etc.  ,  sometimes  with  depositions  of  urates  in  the 
soft  parts  around  the  bone,  adjacent  to  the  bone,  but  not  in  the 
bone. 

Third — \>ry  little  change  in  the  joints,  inflammatory  change 
in  the  soft  parts,  but  no  obvious  deposition  of  urates  in  the  soft 


EXTRACTS  FROM  JOURNALS  273 

parts  about  the  joints  or  in  the  bones  or  cartilage.  In  all  three 
types  depositions  of  urates  in  the  ears  occur  giving  typical  tophi 
that  are  easily  recognized. 

In  regard  to  the  value  of  uric  acid  metabolism  studies,  Chris- 
tian points  out  that  we  are  dealing  with  a  substance  which  is  pres- 
ent in  the  blood  and  in  the  urine  in  relatively  very  small  quanti- 
ties. Anything  present  in  small  quantities  brings  up  the  possibil- 
ity of  error  in  its  determination.  In  the  second  place,  we  are  deal- 
ing with  a  substance  which  in  the  blood  is  very  difficult  of  quanti- 
tive  determination,  and  there  is  still  a  question  as  to  whether  the 
methods  available  are  satisfactory;  or,  to  put  it  another  way,  other 
substances  than  uric  acid  may  cause  the  same  calorimetric  changes 
w'hich  are  used  by  Folin  in  his  method  of  determining  the  uric 
acid. 

In  regard  to  the  x-rays  he  states  that  we  are  justified  in  calling 
gout  only  those  cases  in  which  there  is  the  typical  punched-out 
area  in  the  bones  with  thickening  in  the  bony  substance  around 
the  area. — Henry  A.  Christian,  M.D. 


IXFLUENZA    AIeXIXGITIS. 


Tobler  speaks  of  the  not  infrequent  association  of  suppurative 
meningitis  with  influenza.  We  do  not  as  a  rule  know  whether 
this  complication  is  due  to  Pfeiffer's  bacillus  or  one  of  the  ordi- 
nary pyogenics.  In  seeking  to  throw  light  on  this  subject  the 
author  studied  a  case  in  great  detail.  The  patient  was  an  infant 
5  months  old  with  congenital  syphilis.  It  passed  safely  through 
a  sharp  attack  of  influenza  and  then  underwent  an  inunction  cure. 
Some  weeks  after  recovery  from  influenza  meningeal  symptoms 
suddenly  appeared.  Culture  tests  of  the  spinal  punctuates  were 
negative  throughout  but  hemoculture  yielded  Pfeiffer's  bacillus. 
Despite  the  threatening  character  of  the  meningeal  sequela  death 
occurred  apparently  from  intercurrent  acute  peritonitis.  Autopsy 
revealed  purulent  basal  meningitis  of  base  and  convexity  with  an 
accumulation  of  pus  in  the  peritoneal  cavity  along  with  ordinary 
adhesive  peritonitis.    In  pus  from  both  sources  Pfeiffer's  bacillus 


274     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

was  found  under  the  microscope  in  advance  of  cultures.  This 
case  goes  to  reinforce  a  certain  number  of  others  on  record,  chiefly 
in  young  infants,  in  which  the  meningeal  complication  or  sequela 
was  evidently  not  due  to  mixed  infection.  In  such  cases  the  men- 
ingitis is  doubtless  not  due  to  metastasis  but  to  direct  extension 
of  the  infection. — Medical  Record. 


Scarlet  R  in  Certain  Diseases  of  the  Conjunctiva 
AND  Cornea. 


Writing  in  the  Indian  Medical  Gazette  for  February,  1917, 
Kirkpatrick  states  that  he  has  found  the  use  of  scarlet  R  to  be  so 
beneficial  in  atrophic  conditions  of  the  conjunctival  and  the  cor- 
neal epithelium  that  he  thinks  it  worth  while  to  draw  attention  to 
its  value. 

Scarlet  R  has  been  recommended  for  use  in  corneal  ulceration, 
but  he  has  found  it  much  more  effective  in  xerotic  conditions.  Its 
use  was  first  suggested  to  him  by  seeing  it  recommended  by  a 
writer  in  the  Journal  of  Laryngology  as  a  stimulant  to  the  epi- 
thelium in  atrophic  rhinitis. 

He  first  used  it  two  years  ago  in  the  case  of  a  woman  who  was 
sufifering  from  a  very  severe  exerosis  of  the  conjunctiva  and  cor- 
nea which  had  followed  on  trachoma.  The  condition  was  a  long- 
standing one,  both  cornese  were  quite  dry  and  insensitive,  and  the 
conjunctiva  completely  xerotic,  with  shrunken  fornices.  Vision 
was  reduced  to  the  perception  of  large  objects  near  the  face. 
Scarlet  R  in  castor  oil  was  dropped  into  her  eyes  daily,  and  in  a 
short  time  Kirkpatrick  was  surprised  at  the  improvement  that 
took  place.  The  conjunctiva  softened  and  became  more  elastic, 
whilst  the  cornea  became  clearer  and  allowed  watery  solutions  to 
spread  over  it.  Eventually  it  was  found  possible  to  repair  the  for- 
nices and  she  acquired  useful  vision. 

He  also  found  it  most  valuable  in  cases  of  the  chronic  pannus 
and  superficial  ulceration  of  the  cornea  which  sometimes  persists 
in  trachoma  after  the  conjunctiva  has  cicatrized. 

The  strength  used  has  been  from  ten  to  forty  grains  to  the 
ounce,  according  to  the  amount  of  reaction  excited. — The  Thera- 
peutic Gazette. 


EXTRACTS  FROM  JOURNALS  27S 

OBSTETRICAL 


A  Review  of  Anesthesia  in  Obstetrics. 


In  the  Long  Island  Medical  Journal  for  April,  1917,  Polak  and 
Matthews  publish  an  exhaustive  review  of  this  subject  and  state 
that  the  following  conclusions  may  be  formulated : 

1.  It  must  be  admitted  that  the  ideal  obstetric  anesthesia  has 
not  been  discovered. 

2.  The  prolongation  of.  the  second  stage  of  labor  by  any  method 
is  disastrous  to  the  child,  and  this  is  particularly  true  of  the  mor- 
phine group  of  drugs. 

3.  Various  combinations  of  the  drugs  at  our  disposal  for  the 
production  of  obstetric  anesthesia  have  certain  definite  advantages, 
e.g.,  pantopon  with  scopolamine,  or  morphine  with  scopolamine  to 
carry  the  patient  through  the  preparatory  stages,  and  when  it 
seems  necessary,  chloroform,  ether  or  nitrous  oxide  gas  during 
the  perineal  stage. 

4.  At  the  present  time,  morphine-scopolamine  anesthesia  for 
the  first  stage  and  nitrous  oxide  gas  for  the  second  stage  of  labor, 
would  seem  to  be  the  best  combination. 

5.  From  a  study  of  this  subject,  it  would  seem  that  institutional 
obstetrics  must  be  accepted  as  a  recognized  specialty,  and  that  the 
judicious  use  of  anesthesia,  though  not  without  its  dangers,  is 
destined  to  be  classed  among  the  obstetric  arts. — The  Therapeutic 
Gazette. 


Vaccine  and  Serum  Treatment  of  Puerperal  Septicemia. 


Beruti  concludes  from  his  own  experience  and  the  published 
data,  that  antistreptococcus  serotherapy  in  puerperal  septicemia 
generally  fails.  He  declares  further  that  the  intravenous  route  is 
irrational,  as  also  large  doses  and  attempts  to  use  antistreptococ- 
cus serum  in  prophylaxis.  Better  results  have  been  realized  with 
nonspecific  serotherapy.    Normal  horse  serum  has  given  excellent 


276     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

results  in  the  hands  of  Pouey  and  Turenne  of  Montevideo,  among 
others.  In  one  case  the  leukocytes  rose  from  4,500  to  25,000  under 
it,  and  in  another  case  peritoneal  septicemia  retrogressed.  Beruti 
has  had  a  number  of  notable  recoveries  under  intravenous  injec- 
tion of  normal  horse  or  beef  serum,  the  single  dose  not  over  20 
c.c.  It  is  his  impression  that  the  serum  is  more  potent  therapeu- 
tically when  the  animal  has  been  previously  bled.  The  effect  is 
much  the  same  as  with  the  specific  serums,  but  surpasses  it.  His 
conclusions  as  to  specific  vaccine  therapy  are  that  it  has  not  sus- 
tained its  promise.  Vaccines  made  with  other  bacteria  have 
proved  unexpectedly  effectual  in  the  hands  of  some,  especially  in 
Argentina,  with  Enriquez,  Kraus,  Mazza  and  others,  and  Werner 
at  Vienna  has  reported  excellent  results  with  a  colon  bacillus  vac- 
cine in  puerperal  fever.  Beruti  himself  used  an  extract  of  colon 
bacilli,  instead  of  a  vaccine,  applying  it  in  a  number  of  very  se- 
rious cases  of  puerperal  septicemia  and  with  constantly  unfavor- 
able results.  The  intense  reaction  that  followed  the  intravenous 
injection  was  unmistakably  deleterious.  In  order  to  ascertain  the 
physiologic  bases  for  this  heterotherapy,  he  experimented  on  dogs 
and  rabbits.  What  he  observed  convinced  him  that  there  was 
something  more  involved  in  these  formidable  medicinal  reactions 
than  the  mere  action  of  albuminoids  and  colloids.  But  why  they 
are  so  decidedly  beneficial  in  some  cases  and  so  decidedly  the  re- 
verse in  others  is  still  a  mystery.  It  is  like  shaking  a  clock  that 
has  stopped ;  it  may  start  it  to  going  perfectly  thereafter,  or  it 
may  have  no  effect  or  an  injurious  one.  Costa  regards  the  reac- 
tion to  nonspecific  vaccine  as  a  kind  of  anaphylactic  shock,  liable 
to  do  harm. — The  Journal  of  the  America!  Medical  Association. 


The  Therapeutic  Use  of  the  Extract  of  Corpus  Luteum. 


In  the  Medical  Record  of  May  19,  1917,  Happel  states  that  in  a 
case  of  headache  following  the  menopause,  due  to  insufficient  in- 
ternal secretion  of  the  ovary,  the  extract  of  corpus  luteum  is  a 
specific. 

Extract  of  corpus  luteum  must  be  given  over  a  long  period  of 
time  and  in  sufficient  dosage,  according  to  the  needs  of  the  pa- 


EXTRACTS  FROM  JOURNALS  277 

tient.  It  produces  no  toxic  effect,  except  a  feeling  of  fulness  of 
the  head  or  vertigo,  and  is  not  cumulative. 

It  is  the  best  remedy  for  the  relief  of  the  nervous  symptoms 
of  the  natural  menopause,  and  for  their  prevention  and  relief  in 
post-operative  menopause. 

It  is  of  the  greatest  value  in  the  treatment  of  irregular  or  scanty 
menstruation  in  young  women  and  alleviates  the  neurasthenic 
symptoms  so  often  associated. 

It  relieves  dysmenorrhea  in  young  girls  and  nulliparae  not  due 
to  a  pathological  lesion. 

Benefit  in  nausea  and  vomiting  of  pregnancy  has  been  reported. 

The  only  disadvantage  is  the  cost,  which  precludes  its  use  in 
many  cases  in  which  it  is  strongly  indicated. — The  Therapeutic 
Gazette. 


278     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


lEitlnml 


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A  Critical  Situation. 


The  government  is  raising  an  immense  army  of  volunteers  and 
conscripts  to  carry  on  the  war  to  a  successful  and,  we  hope,  an 
early  termination. 

Every  army  must  be  supplied  with  a  personnel  of  medical  offi- 
cers of  adequate  number  and  well  trained.  While  provisions  have 
been  made  to  raise  the  required  number  of  men  for  the  fighting 
force,  it  has  been  left  to  members  of  the  medical  profession  of 
this  country  to  come  forward  voluntarily,  seeking  commissions  in 
the  Medical  Reserve  Corps. 

Only  a  few  of  the  total  number  required  have  applied  for  com- 
missions. This  means  that  unless  immediate  action  is  taken  by 
the  profession  voluntarily,  the  men  in  the  army  now  being  organ- 
ized will  be  without  sufficient  medical  care.  Such  a  condition 
would  be  more  than  critical  and  dangerous  for  the  success  of  our 
army  and  the  cause  in  which  we  are  enlisted.  The  medical  officer 
plays  a  most  prominent  part  not  only  in  keeping  the  army  on  its 
feet  and  physically  fit  for  fighting,  but  in  returning  to  the  ranks 
a  large  percentage  of  those  who  have  been  temporarily  put  out 
through  casualties. 

How  soon  will  the  medical  profession  of  the  United  States  as  a 
whole  wake  up  and  realize  that  doctors  must  come  forward  and 
volunteer  their  services  to  the  government? 


EDITORIALS  279 

In  civil  life,  when  great  casualties  occur,  the  doctor  readily 
offers  his  services  and  usually  is  the  first  on  the  scene  to  save 
human  life.  How  much  more  important  is  it,  then,  that  in  this 
critical  situation,  he  should  come  forward  and  offer  his  valuable 
aid  to  preserve  not  only  human  lives,  but  the  life  of  the  nation 
itself? 

Application  blanks  for  commissions  in  the  Medical  Reserve 
Corps  are  being  printed  in  many  medical  journals  or  will  be  sent 
to  you  by  the  Surgeon  General's  office,  or  can  be  secured  from 
members  of  the  local  board  of  examiners. 

If  you  are  not  acquainted  with  such  a  board,  the  editor  of  this 
Journal  will  be  glad  to  advise  you.  One-fifth  of  the  active  pro- 
fession of  the  United  State  is  all  that  is  required  to  supply  the 
army  now  being  raised.    Be  a  part  of  the  one-fifth. 


Rapid  Growth  of  the  Birth  Registration  Area. 


Washington,  D.  C.,  September  12,  1917 — Congratulations  to 
Maryland,  Virginia,  and  Kentucky,  the  latest  states  to  be  admit- 
ted to  the  Registration  Area  for  Births  by  the  Director  of  the 
Census,  Sam  L.  Rogers. 

The  Registration  Area  for  Births  was  established  in  1915,  and 
was  then  composed  of  ten  states  and  the  District  of  Columbia, 
representing  10  per  cent  of  the  territorial  extent  of  the  United 
States,  but  containing  31  per  cent  of  the  country's  population. 
For  this  area  the  Bureau  of  the  Census  has  recently  issued  its 
first  annual  report,  entitled  "Birth  Statistics."  As  the  area  grows 
the  annual  reports  will  deal  with  the  births  in  a  constantly  in- 
creasing portion  of  the  country  and  will,  therefore,  become  of 
constantly  increasing  interest  and  value. 

The  outlook  for  a  very  rapid  growth  of  this  Registration  Area 
for  Births  is  so  good  that  a  word  of  cheer  to  the  states  outside 
should  be  given.  The  need  of  complete  birth  registration  is  rec- 
ognized now  as  never  before.  The  age  of  the  soldier  must  be 
known,  and  so  a  new  argument  for  birth  registration  comes  to  the 


280     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

United  States.  Since  war  was  declared  tests  of  the  completeness 
of  birth  registration  have  been  made  by  special  agents  of  the  Cen- 
sus Bureau  of  Virginia  and  Kentucky,  and  both  these  states  se- 
cured a  rating  of  over  90  per  cent,  which  represents  the  degree 
of  completeness  required  for  admission  to  the  area. 

Similar  tests  are  now  being  made  in  Indiana  and  New  Jersey, 
and  before  the  year  is  over  will  be  conducted  in  North  Carolina, 
Ohio,  Utah,  and  Wisconsin.  Several  other  states  are  nearly 
ready  to  seek  admission,  and  it  is  by  no  means  a  wild  prediction 
that  the  Birth  Registration  Area  within  the  next  two  years  will 
be  more  than  trebled  in  size,  and  will  contain  over  two-thirds  of 
the  population  of  the  United  States. 

One  physician  recently  became  so  thoroughly  aroused  to  the 
desirability  of  recording  births  that  he  reported  to  the  local  reg- 
istrar 450  births  which  had  occured  in  this  practice  since  1900. 

Parents  and  physicians  everywhere  are  awakening  to  the  im- 
portance of  this  matter  and  the  fashion  now  is  to  register  baby's 
birth. 


The  article  on  Epilepsy  in  this  number  of  the  Journal  was  writ- 
ten by  Dr.  C.  L.  Lewis  many  years  ago  and  is  presented  to  show 
the  few  changes  that  have  taken  place  in  the  pathology  and  treat- 
ment of  the  disease  since  that  time.  It  is  an  excellent  sketch  of 
the  disease. 


Nashville  Journal  of  Medicine  and  Surgery,  Nashville,  Tenn. 

Gentlemen — The  American  Association  of  Orificial  Surgeons 
hold  their  annual  meeting  in  Chicago  at  the  Congress  Hotel,  Sep- 
tember 27,  28  and  29. 

The  morning  hours  are  devoted  to  surgical  clinic  at  Fort  Dear- 
born Hospital. 

Notice  of  this  meeting  in  your  Journal  will  be  greatly  appre- 
ciated.    I  am.  Very  fraternally  yours, 

B.  A.  Bullock. 


EDITORIALS  281 

Little  Pure  Zixc  Oxide  on  the  Market. 


Washing-ton,  D.  C. — Examinations  made  by  the  Bureau  of 
Chemistry  of  the  United  States  Department  of  xA.gricuIture  show 
that  very  Httle  zinc  oxide  on  the  market  in  the  United  Staes  com- 
pHes  with  the  standards  of  the  U.  S.  Pharmacopoeia.  Nearly  all 
of  the  samples  examined  contained  an  excessive  amount  of  lead. 
The  samples  were  labeled  ''Not  U.  S.  P. — Containing  Small  Puan- 
tities  of  Lead,,'  and  therefore  complied  with  the  Food  and  Drugs 
Act.  The  labels  on  the  packages  in  most  instances  will  probably 
come  to  the  attention  of  the  druggists,  but  not  to  the  attention  of 
physicians.  The  medical  profession  will  therefore  not  be  advised 
as  to  whether  or  not  zinc  oxide  preparations  are  made  from  stand- 
ard ingredients.  Conditions  may  arise  where  a  zinc  oxide  prep- 
aration contaminated  with  lead  may  do  injury.  A  limited  supply 
of  U.  S.  P.  zinc  oxide  is  available  and  physicians  may  protect 
themselves  and  their  patients  from  possible  injury  by  calling  for 
such  material  on  their  prescriptions. 


Stand  Behind  Our  Fighting  ^vIen, 


America  today  is  filled  with  young  men  of  the  country  who 
wear  their  country's  uniform  and  who  have  offered  their  lives  to 
the  service  of  their  country.  Every  city,  every  town,  every  ham- 
let, every  country  community  has  some  of  its  boys  in  the  military 
uniform  of  their  country.  They  are  the  very  flower  of  our  young 
manhood. 

These  are  the  men  who  are  to  go  to  the  battle  front.  How  effec- 
tive they  will  be  there,  how  safe  they  will  be  there  depends  on  the 
support  that  their  country  gives  them.  The  slower  the  United 
States  is  to  exert  its  full  power  and  put  an  end  to  the  carnage  in 
Europe  the  more  of  those  Americans  who  are  now  in  France  and 
those  who  soon  are  to  join  them  will  suffer  death  and  the  greater 
number  of  American  homes  will  be  made  desolate. 

It  is  not  to  be  believed  that  some  national  catastrophe,  some 
calamity  that  will  be  shameful  to  us  if  it  comes  from  lack  of  prep- 


282     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

aration  or  from  our  failure  to  stand  behind  our  soldiers,  must 
occur  to  awaken  our  people  to  their  duty. 

The  soldiers  of  the  United  States  are  standing  by  their  country 
with  a  steady  courage  and  devotion  to  duty  that  should  inspire 
the  Nation  with  pride  and  patriotism  and  loyalty.  Some  of  them 
now  are  facing  death  for  their  people,  are  participating  in  the 
great  battles  in  Europe  to  make  the  world  safe  for  Democracy, 
to  insure  our  own  safety  and  to  vindicate  our  honor.  We  who 
remain  here  in  peace  and  safety  must  surely  do  our  part. 

The  Liberty  Loan  of  1917  was  authorized  for  the  purpose  of, 
and  its  proceeds  are  being  spent  in  arming,  equipping,  supplying 
and  caring  for  the  soldiers  of  the  United  States  and  to  assist  our 
allies  who  are  fighting  by  their  side  in  France.  In  supporting  the 
Liberty  Loan  the  people  of  America  are  supporting  our  soldiers, 
and  standing  behind  the  men  behind  the  guns.  We  should  sup- 
port our  soldiers  with  all  of  our  means,  all  of  our  resources,  all  of 
the  combined  might  and  power  of  the  great  nation  that  we  are. 


Suicide  Among  Wage  Earners  and  the  General 
Population  Compared. 


Among  both  white  male  and  female  policy-holders  of  the  com- 
pany, under  25  years  of  age,  the  suicide  death  rates  are  lower  than 
those  recorded  among  males  and  females  in  the  general  population 
of  the  Registration  Area  of  the  United  States.  For  each  age  pe- 
riod after  25,  the  suicide  rate  of  insured  males  is  slightly  higher 
than  for  the  male  population  at  large.  White  females  insured 
in  the  company,  however,  show  a  lower  rate  than  females  in  the 
general  population  throughout  life. 

If  the  suicide  rates  is  an  indication  of  the  mental  health  of  the 
people,  it  would  appear  from  these  figures  that  the  housewives  of 
the  industrial  families  of  the  country  are  the  best  balanced  of  all. 
Their  husbands  are  not  quite  so  well  favored. 


EDITORIALS  283 

Insuring  Our  Soldiers  and  Sailors. 


That  a  nation  owes  much  to  its  citizens  who  have  fought  its 
battles  and  to  their  famiHes  when  they  have  been  killed  or  injured 
so  as  to  destroy  or  impair  their  capacity  to  provide  for  their  fami- 
lies has  always  been  recognized  by  the  United  States.  This  just 
and  generous  policy  of  our  country  as  administered  under  our 
pension  system  has  been  unduly  costly  and  has  not  always  been 
just.  One  of  the  proposed  uses  of  the  proceeds  of  the  Liberty 
Loan  is  to  give  life  and  indemnity  insurance  to  our  soldiers  and 
sailors  and  to  provide  allowances  to  their  dependent  families  while 
they  are  in  the  ranks. 

The  plan  worked  out  by  Secretary  of  the  Treasurer  McAdoo 
and  his  coadjutors  and  approved  by  the  President  has  been  em- 
bodied in  a  bill  which  is  now  pending  in  Congress.  As  to  the 
justness  and  righteousness  of  this  insurannce  of  our  fighting  men 
Secretary  McAdoo  says: 

"Military  service  in  the  United  States  is  obligatory ;  those  who 
imperil  themselves  have  no  election.  The  insurance  companies 
do  not  and  can  not  permit  this  to  affect  their  calculations.  They 
must  protect  themselves  by  charging  premiums  so  high  that  they 
are  secured  against  loss  no  matter  how  severe  the  rate  of  mortal- 
ity may  be.  Consequently  the  very  men  who  are  called  into  the 
service  because  their  physical  condition  is  of  the  best  and  who  as 
civilians  would  for  that  reason  be  able  to  secure  the  most  favorable 
insurance  rate  in  peace  time,  are  denied  as  soldiers  the  necessary 
life  insurance  to  enable  them  to  protect  their  families  and  depend- 
ents. The  extra  hazardous  risks  of  war  puts  insurance  entirely 
beyond  the  reach  of  the  conscripted  soldier. 

"The  government  which  subjects  these  men  to  this  insurmount- 
able discrimination  should  itself  supply  insurance  to  soldiers  at 
cost  and  upon  the  peace  basis.  It  would  in  fact  be  dastardly  and 
undemocratic  if  the  government  should  penalize  the  soldier  who 
is  forced  to  render  the  highest  duty  of  the  citizen,  by  failing  to 
provide  for  him  war  insurance  upon  peace  terms  and  at  net  cost. 
The  pay  of  the  enlisted  men  in  the  Army  and  Navy  is  less  than 


284     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

the  wages  and  salaries  generally  earned  in  private  life  and  gov- 
ernment insurance  is  an  essential  war  and  emergency  measure  in- 
augurated for  the  specific  benefit  of  our  military  forces  and  can 
not  be  conducted  for  profit. 

"This  legislation  will  be  a  great  step  forward  in  the  recognition 
of  the  Republic's  duty  to  its  heroes.  It  deserves  earnest  and  vig- 
orous support  of  the  country.  The  United  States  should  set  the 
highest  example  of  all  the  nations  in  the  treatment  of  those  who 
do  and  die  for  their  country  and  for  world  freedom." 


REVIEWS  AND  BOOK  NOTICES  286 


%eiiUhiB  mh  %0ok  Nottr^B 


Handbook  of  Gynecology  for  Students  and  Practitioners — By  Henry 
Foster  Lewis,  A.B.,  M.D.,  Professor  and  Head  of  Department  of  Ob- 
stetrics and  Gj-necology  in  Loyola  University  School  of  Medicine; 
Chief  of  Obstetric  Staff  of  Cook  County  Hospital;  Fellow  and  Ex- 
President  of  the  Chicago  Gynecological  Society;  Late  Assistant  Pro- 
fessor of  Obsterics  and  Gynecology  in  Rush  Medical  College  (in  affil- 
iation with  the  University  of  Chicago),  and  Alfred  de  Roulet,  B.Sc, 
M.D.,  Professor  of  Gynecologj-  in  Loyola  University  School  of  Medi- 
cine; Attending  Gynecologist  to  the  Home  of  the  Good  Shepherd  and 
to  St.  Bernard's  Hospital;  Obstetrician  and  Chief  of  Staff  of  St.  Mar- 
garet's Home  and  Hosprtal.  With  One  Hundred  and  Twenty-seven 
Illustrations.     St.  Louis.    C.  V.  Mosby  Company.     1917. 

In  the  examination  of  this  new  claimant  for  professional  favor 
we  have  been  struck  with  the  essentially  practical  character  of  the 
work.  It  is  excellently  adapted  to  the  needs  of  the  student  and 
will  prove  a  great  help  to  the  young  practitioner.  The  arrange- 
ment is  unusual — out  of  the  line  generally  adopted  by  text-books — 
but  systematic  and  logical.  The  illustrations  are  numerous  and 
good.  Operative  technique  is  presented  briefly  but  clearly  and 
concisely.  The  authors  rightly  claim  that  technique  can  be  ac- 
quired only  by  hospital  work,  not  by  text-book  descriptions.  All 
in  all  the  book  is  a  valuable  contribution  to  medical  literature  and 
should  be  well  received. 


Practical  Materia  Medica  and  Prescription  Writing,  with  Illustrations 
by  Oscar  W.  Bethea,  M.D.,  Ph.G.,  F.  C.  S.;  Assistant  Professor  of 
Materia  Medica  and  Instructor  in  Prescription  Writing,  Tulane  Uni- 
versity of  Louisiana,  Formerly  Professor  of  Chemistry  and  Professor 
of  PharmacologJ^  Mississippi  Medical  College,  etc.  Second  Revised 
Edition.  Philadelphia.  F.  A.  Davis  Company,  Publishers.  English 
Depot,  Stanley  Phillips,  London.     1917. 

We  are  indebted  to  the  obliging  publishers  of  this  useful  work 
for  a  copy  of  the  second  edition,  enlarged  and  rewritten.  As  a 
text-book  of  materia  medica  for  the  daily  use  of  practitioner  and 
student  it  is  a  carefully  prepared  compend  covering  the  entire 
field  of  materia  medica  and  pharmacology  in  a  practical  and  con- 
cise manner.  An  especially  valuable  portion  of  the  work  is  part 
third,  devoted  to  the  art  of  writing  prescriptions,  an  art  some- 


286     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

what  neglected  by  the  majority  of  physicians.  In  this  part  fifty 
prescriptions  are  arranged  illustrating  common  errors  of  prescrip- 
tion writing  as  compared  with  the  same  prescription  correctly 
formulated.  These  have  been  selected  from  thousands  of  pre- 
scriptions and  the  idea  is  not  only  to  point  out  errors,  but  to  give 
formula  of  therapeutic  merit.  We  regard  the  work  as  of  real 
value  and  do  not  hesitate  to  recommend  it  to  student  and  prac- 
titioner. 


PUBLISHERS'  DEPARTMENT  287 


Puhltslf^r  H  i^parttttFut 


In  Pruritus. 


Even  in  severe  forms  of  genital,  anal,  diabetic,  eczematous  itching, 
K-Y  Lubricating  Jelly  in  a  great  majority  of  cases,  will  bring  relief,  or 
at  least  grateful  alleviation. 

To  anoint  the  skin  in  these  conditions,  K-Y  Lubricating  Jelly  is  not 
only  effective,  but  convenient  and  economical,  since  it  can  be  used 
without  staining  or  soiling  the  bed  clothes  or  the  patient's  linen.  If  the 
part  is  washed  before  each  application,  the  .best  results  are  obtained. 


In  Neuritis,  is  the  hot  water  bottle  the  best  anodyne?  Palliation,  by 
means  of  externally  applied  heat,  is  just  as  popular  today  as  it  was  in 
Hippocrates'  time. 

The  hot  bath  and  the  hot  water  bottle  are  wonderful  comforters.  But 
who  can  be  continuously  in  the  bathtub,  or  who  can  be  forever  carry- 
ing a  hot  water  .bottle?  And  how  all  too  soon  does  the  most  faithful  hot 
water  bottle  lose  its  ardor  and  its  temperature! 

There  is  no  simple  adjunct  in  this  category  more  simple  and  more 
generally  effective  than  application  by  the  patient  himself,  if  possible 
along  the  course  of  the  affected  nerve,  with  K-Y  ANALGESIC  (methyl- 
salicylate,  camphor  and  menthol,  combined  in  a  non-greasy,  water- 
soluble  base.) 

K-Y  ANALGESIC  has  the  obvious  advantage  over  the  hot  water  .bot- 
tle in  that  "it  stays  put"  for  a  much  greater  period  of  time.  Nor  is 
there  the  possible  danger  of  a  hot  water  bottle  burn — a  factor  especially 
to  be  thought  of  where  the  neuritis  patient  is  weak  and  infirm. 


"Paraldehyd"  possesses  many  of  the  good  without  the  evil  qualities 
of  chloral.  Used  in  Insomnia  resulting  from  various  causes.  The  ob- 
jectionable taste  of  the  chemical  is,  to  a  great  extent,  disguised  in  Rob- 
inson's Elixir  Paralydehyd  (see  advertisement  in  this  issue)  which  is 
an  elegant  preparation. 


Are  You  Seeking  a  Reliable  Tonic? 


Conservative  medical  men  are  neither  asked  nor  expected  to  accept 
the  opinions  or  conclusions  of  anyone  else  concerning  the  value  of 
Gray's  Glycerine  Tonic  Comp.  The  only  request  of  the  manufacturers 
is  that  the  physician  who  is  seeking  a  tonic,  a  dependable  means  of  re- 
storing the  activity  of  the  bodily  functions,  will  give  this  remedy  a 
fair  and  reasonable  trial.  To  his  conclusions  as  to  the  results  obtained 
— his  judgment  as  to  the  superiority  of  this  remedy  as  a  means  of  over- 
coming debility,  inanition  and  malnutrition — the  decision  as  to  its  use 
in  the  treatment  of  debilitated  conditions  is  cheerfully  left.  Knowledge 
of  what  careful,  painstaking  physicians,  however,  are  doing  with  Gray's 
Glycerine  Tonic  Comp.  whenever  a  tonic  is  indicated,  leaves  no  doubt 


288      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

of  what  that  judgment  will  be,  for  it  has  been  shown  beyond  all  pos- 
sible question  that  this  efficient  therapeutic  agent  has  no  superior  in 
its  field  of  use. 

If  you  have  some  troublesome  case  in  which  you  would  like  to  try 
"Gray's" — write  today  to  the  Purdue  Frederick  Company,  135  Christo- 
pher St.,  New  York  City. 


Tertiary  Syphilis. 


As  a  means  of  controlling  tertiary  syphilis  lodia  (Battle)  is  of  proven 
worth.  The  iodine  content  insures  a  direct  action  against  deposits  and 
'infiltrations,  and  brings  about  their  resolution. 

A  marked  advantage  of  lodia  (Battle)  in  syphilis  lies  in  the  patient's 
tolerance,  as  a  result  of  which  it  may  be  crowded  and  continued  indefi- 
nitely with  a  minimum  of  untoward  effects.  The  value  of  lodia  (Battle) 
as  an  antisyphilitic  agent  has  been  demonstrated  for  years,  and  that 
its  employment  is  wider  today  than  ever  is  the  best  evidence  of  the 
estimation  in  which  it  is  held  by  the  medical  profession. 


The  Cerebral  Irritation  of  Typhoid. 


One  of  the  most  important  symptoms  of  typhoid  fever  is  the  cerebral 
irritation  caused  by  the  infection.  The  patient  is  already  weakened 
through  the  severe  infection  and  it  is  necessary  to  choose  a  cer&bral 
sedative  that  will  caim  the  patient  and  at  the  same  time  be  free  from  a 
depressing  influence  on  the  neart. 

Pasadyne  (Daniel)  is  used  by  many  hundreds  of  physicians  for  this 
very  reason,  it  exerts  a  potent  sedative  effect,  yet  does  not  depress  or 
produce  bad  after-effects. 

Pasadyne  (Daniel)  is  the  ideal  sedative  and  especially  when  the 
patient  is  already  weakened  by  reason  of  infection.  Pasadyne  (Daniel) 
Is  simply  a  pure  concentrated  tincture  of  passiflora  incarnata.  A  sam- 
ple bottle  may  be  had  by  addressing  the  laboratory  of  John  B.  Daniel, 
Inc.,  Atlanta,  Ga. 


Prevention  of  Bronchial  and  Pulmonary  Infections. 


The  value  of  cod  liver  oil  as  a  meas  of  guarding  against  bronchial 
and  pulmonary  infections  by  raising  the  index  of  resistance  of  the  con- 
cerned tissues,  is  well  appreciated  by  the  profession,  and  many  physi- 
cians advise  the  systematic  use  of  Cord.  Ext.  Ol.  Morrhuae  Comp. 
(Hagee)  for  this  purpose.  It  would  appear  that  cod  liver  oil  has  a 
definite  predilection  for  the  tissues  of  the  lungs  and  bronchi  and  adds 
materially  to  their  powers  of  resistance  against  germ  invasion.  That 
this  increase  of  resisting  power  means  a  diminution  of  susceptibility 
to  colds  and  their  consequences  is  very  evident  and  points  plainly  to  the 
need  for  a  cod  liver  oil  preparation,  such  as  Cord.  Ext.  01.  Morrhuae 
Comp.  (Hagee)  in  those  persons  with  the  slightest  susceptibility  to 
bronchial  and  pulmonary  infections.  The  superior  feature  of  Cord.  Ext. 
Ol.  Morrhuae  Comp.  (Hagee)  is  its  palatability  which  in  no  wise  im- 
pairs its  therapeutic  efficacy. 


NASHVILLE  JOURNAL 

—  or  — 

MEDICINE  AND    SURGERY 


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


Vol.  CXI.  OCTOBER,  1917.  No.  10 


®ngtnal  Ql0mmuntrattdn0 


SOME  EFFECTS  OF  INEBRIETY  ON  THE  TEETH 
AND  JAWS. 


BY  T.  D.  CROTHERS,   M.D., 

Supt.  Walnut  Lodge  Hospital,  Hartford,  Conn. 


Some  years  ago  through  the  courtesy  of  Dr.  Talbot  my  atten- 
tion was  called  to  the  degenerations  of  the  teeth  and  jaws  in  per- 
sons who  had  used  spirits  and  drugs  to  excess.  General  marks  of 
degeneration,  seen  in  the  head  and  face  and  other  parts  of  the 
body,  have  been  commonly  noted  in  inebriates  but  we  owe  to 
Dr.  Talbot  the  credit  of  showing  that  certain  of  these  defects  were 
traceable  to  spirit  and  drug  taking,  both  as  an  active  and  pre- 
disposing cause. 

My  work  for  forty  years  has  been  almost  exclusively  confined 
to  the  study  of  inebriates  from  spirit  and  drug  taking.  This  has 
given  me  an  opportunity  to  note  many  facts  along  these  lines  and 
confirm  and  verify  the  statements  of  others.  In  an  analysis  of 
the  histories  of  a  large  number  of  inebriates,  at  least  seventy  per 
cent  will  be  found  to  inherit  from  their  ancestors  neurotic  defects 
and  faults  of  vitality  and  nutrition.    The  remaining  thirty  per  cent 


290     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

are  traceable  to  injuries,  diseases,  bad  nutrition  and  environment. 
The  first  class  show  marks  of  this  neurotic  heredity  in  defects  of 
the  body  and  deficient  vitality.  The  second  class  are  more  prom- 
inent in  general  symptoms  of  anaemia,  starvation  and  poisoning. 

The  brain,  nervous  system  and  functional  activities  reflect  these 
conditions  in  many  ways.  Thus  in  the  inherited  class  the  head, 
face,  teeth  and  maxillaries  all  show  degrees  of  symmetry  whicn 
point  to  irregular  and  retarded  growth  and  faults  of  nutrition. 

In  the  acquired  class  the  faults  of  nutrition  with  irregular  con- 
trol and  feeble  brain  function  and  vigor  are  prominent. 

The  direct  action  of  spirits  on  the  mouth  and  teeth  is  due  in 
some  degree  to  the  rapid  water  absorbing  qualities  of  alcohol. 
Alcohol  on  the  surface  absorbs  the  moisture  so  rapidly  that  it  be- 
comes an  irritant  corrugating  the  tissue.  In  the  mouth,  it  has  the 
same  efifect  which  is  neutralized  in  a  measure  by  the  excessive 
salivary  discharge. 

It  has  been  noted  that  spirit  and  beer  drinkers  who  take  small 
quantities  of  spirits,  sipping  them  over  long  periods  of  time  have 
defective  teeth  and  gums  while  others  who  drink  spirits  with 
large  quantities  of  water,  swallowing  them  rapidly,  do  not  suffer 
so  much.  Persons  who  use  beer  and  spirits  to  gratify  the  sense 
of  taste  and  enjoy  the  flavors,  always  sufifer  from  degeneration  of 
the  mucous  membrane,  gums  and  teeth.  Often  such  defects  are 
unnoticed  until  the  spirits  and  drugs  are  removed  and  the  anes- 
thetic condition  which  has  existed  passes  away,  then  the  exposed 
nerves  and  crumbling  teeth  call  for  help. 

The  use  of  alcohol  produces  vaso-motor  paralysis  by  which  the 
circulation  of  the  blood  is  retarded  and  deranged.  The  nutriti- 
tion  of  tissue  and  cell  is  lowered  and  impoverished.  Added  to 
this  there  is  an  increase  of  toxins  with  leukocytes  and  deficient 
power  of  elimination ;  hence  both  starvation  and  poisoning  fol- 
low. The  terminal  arterioles  are  deranged  and  the  cells  and  den- 
trites  suffer  from  defective  nutrition  from  the  toxns. 

I  think  that  the  same  process  takes  place  in  the  terminal  nerves 
of  the  teeth  and  gums  that  is  noted  in  the  nerves  of  the  extremi- 
ties in  neuritis.  There  is  without  doubt  a  very  close  association  be- 


ORIGINAL  COMMUNICATIONS  291 

tween  neuritis  and  dental  degeneration,  and  in  my  experience  they 
frequently  follow  each  other. 

Spirit  and  drug  takers  who  complain  of  so-called  rheumatsm, 
particular  pain,  stiffness  of  the  joints  and  defective  locomotion 
have  neuritis  and  toxaemic  states  affecting  the  cell  and  dentrites  at 
the  extremities.  The  crumbling  teeth  and  shrunken  gums  is  an- 
other S}TOptom  of  what  appears  to  be  the  same  pathological  pro- 
cess of  acute  nerve  poisoning. 

The  toxin  of  syphilis  shows  itself  often  in  the  faulty  growth  and 
condition  of  the  teeth  and  gums.  Lead  and  other  poisons  are  mani- 
fest in  the  same  way.  The  profesesion  is  not  aware  that  alcohol  is 
a  toxemic  in  its  effects  on  nutrition,  and  it  is  only  recently  that  we 
are  confronted  with  the  evidence  that  alcohol  is  cumulative  in  its 
effects. 

The  steady  use  of  spirits  even  in  small  doses,  such  as  wine  at 
meals  taken  with  the  utmost  regularity  for  a  long  time,  is  a  source 
of  degeneration  that  is  as  clearly  traceable  as  that  of  syphilis.  In 
physics  the  continual  tapping  by  a  hammer  on  the  hardest  steel 
will  after  a  time  break  up  its  tenacity  and  cohesiveness,  causing  it 
to  crumble  like  chalk.  In  like  manner  the  continued  use  of  a 
dose  of  spirits  acting  on  the  vaso-motor  centers,  deranging  cir- 
culation and  nutrition,  increasing  the  toxins  and  diminishing  the 
power  of  elimination  produces  permanent  erosions  and  degen- 
erations of  cells  and  tissues.  Fibrinous  deposits  and  sclerosis  of 
the  nerves  and  tissue  are  always  present  in  such  cases.  Metabolism 
and  vitality  are  slowly  and  surely  destroyed  and  this  condition  is 
transmitted  to  the  next  generation,  appearing  in  convulsive  degen- 
erations, recurrent  insanities  and  morbid  impulses  for  spirits  and 
drugs. 

So-called  moderate  drinkers  who  imagine  that  their  temperate 
use  of  spirits  was  a  virtue  with  increased  enjoyment  of  life  have 
m  reality  crippled  and  destroyed  the  next  generation  by  trans- 
mitting to  them  defects  that  are  continuous  evidence  of  the  degen- 
eration from  the  use  of  spirits. 

Dentists  as  well  as  physicians  are  constantly  confronted  with 
these  evidences  of  the  failure  of  parents  to  transmit  to  the  next 
generation  normal  vigor  and  vitality.     If  associated  with  the  use 


292     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

of  spirits  either  in  excess  or  moderation,  there  is  hyper-nutrition ; 
the  toxsemic  conditions  are  very  greatly  increased  and  this  is  seen 
in  the  teeth  and  mouth. 

Formerly  unthinking  physicians  prescribed  alcohol  and  drugs 
as  remedies  which  covered  up  this  condition.  Often  persons  who 
have  local  inflammation  of  the  dental  nerves  find  that  spirits  and 
drugs  give  temporary  relief  and  very  soon  continue  its  use  and 
become  habitues.  The  defects  of  the  teeth  become  intensified 
and  finally  they  are  removed  as  a  remedy. 

Many  persons  believe  that  the  local  inflammation  of  the  gums 
and  teeth  was  the  active  cause  of  the  drug  addiction.  Cocaine 
taking  is  frequently  contracted  by  the  use  of  this  drug  for  the  de- 
fects on  the  gums.  Other  drug  addictions  may  spring  from  the 
same  cause,  but  it  is  evident  that  the  localized  efifect  on  the  teeth 
and  gums  point  to  the  same  grave  condition  affecting  the  entire 
body  and  that  spirit  and  drug  taking  are  only  culminations  of 
degenerations  beginning  long  before. 

Morphia  takers  always  have  defective  teeth  and  a  general  ma- 
rasmic  condition  of  the  mouth.  The  continued  anesthesia  of  the 
sensory  centres  not  only  increases  the  degeneration  but  covers  up 
all  evidences  of  it.  In  some  of  the  opium  addictions  there  is 
great  hyperesthesia  of  the  gums  and  teeth ;  in  others  marked  anes- 
thesia appears.  In  most  of  the  persons  I  see  who  use  this  drug  to 
excess,  the  active  degeneration  goes  on  in  the  mouth  without  any 
recognition  of  it,  but  the  moment  the  drug  is  removed  the  condi- 
tion becomes  intensified  and  very  prominent.  Occasionally  teeth 
that  are  sound  become  the  center  of  extreme  pain.  The  entire 
dental  nerve  and  its  branches  seem  to  be  in  a  condition  of  acute 
inflammation  and  even  after  the  teeth  have  been  removed  obstinate 
neuralgias  continue.  A  sudden  acute  localized  inflammation  of  the 
dental  nerves  should  be  regarded  as  neuritis  with  distinct  causes, 
prominent  of  which  are  alcohol  and  narcotics,  also  lead  and  mer- 
cury. I  have  met  a  few  persons  whose  morphinism  developed  an 
acute  hyperesthesia  of  the  maxillary  nerves.  Every  effort  to  re- 
move the  drug  was  followed  by  a  return  of  the  pain  and  suffering 
until  finally  the  case  became  chronic  and  all  treatment  was  aban- 
doned.    I  have  seen  two  such  cases  who  are  comfortable  while 


ORIGINAL  COMMUNICATIONS  293 

using  morphia  but  the  removal  brought  on  the  most  aggravating 
suffering.  In  one  instance  reported  to  me  where  the  morphia  had 
been  removed,  a  surgical  operation  was  resorted  to  and  the  nerve 
severed  but  the  pain  continued.  The  removal  of  the  teeth  does 
not  always  check  the  pain.  The  nerve  becomes  permanently  dis- 
organized. 

It  is  an  interesting  question  in  the  study  of  the  causes  to  know 
how  far  alcohol  or  other  narcotics  have  had  primary  or  secondary 
effects  on  the  teeth  and  gums.  Where  dental  defects  existed  be- 
fore drug  taking  some  constitutional  condition  existed  usually 
manifest  in  that  way.  _Some  very  unusual  cases  have  come  under 
my  observation  where  profound  shocks  and  derangements  of 
nutrition  have  resulted  in  inflammation  and  erosion  of  the  teeth. 
The  following  is  an  example : 

A  business  man,  aged  45,  temperate,  with  no  heredity,  was 
made  unconscious  by  a  lightening  stroke  in  his  immediate  vicin- 
ity. Invalidism  without  any  distinct  symptoms  lasted  for  two 
months,  then  suddenly  he  began  to  use  spirits  to  great  excess  and 
came  under  my  care.  In  a  short  time  the  craze  disappeared  en- 
tirely, then  acute  maxillary  inflammation  began  extending  to 
every  tooth  of  the  mouth.  There  was  no  evidence  of  decay,  only 
extreme  hyperesthesia  of  the  gums  and  tenderness  of  the  teeth. 
All  local  and  general  treatment  failed  and  he  went  under  the  care 
of  a  nerve  specialist.  A  year  later  he  returned  as  a  morphia 
taker.  His  teeth  had  all  been  removed  but  the  pain  along  the  max- 
illary continued  except  when  under  the  narcotism  of  morphia. 

A  second  example  was  a  similar  temperate  business  man  in 
good  health  up  to  the  death  of  his  wife  from  an  accident.  A  few 
weeks  later  acute  inflammation  of  the  teeth  and  gums,  with  great 
sensitiveness  to  heat  and  cold  in  the  mouth,  came  on.  Active  treat- 
ment by  a  dentist,  with  the  removal  of  the  teeth,  was  followed  by 
improvement.  He  then  became  an  alcoholic  inebriate.  Under  my 
care  he  was  treated  with  electricity  and  recovered  both  from 
degeneration  of  the  mouth  and  the  use  of  spirits. 

There  was  probably  in  these  cases  some  profound  tox^emic 
condition  associated  with  the  psychical  shocks  in  both  cases  which 
localized  in  the  maxillaries.     I  have  the  histories  of  several  per- 


294     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

sons  who  before  all  use  of  spirits  and  drugs  had  a  prolonged 
period  of  dental  troubles  in  which  nearly  every  tooth  was  filled 
and  later  they  all  broke  down. 

The  history  of  specific  taints  with  salivation  from  mercury  and 
loss  of  teeth,  then  spirit  and  drug  taking  are  very  common.  In 
some  persons,  forms  of  neuronic  exhaustion  precede  the  break- 
ing down  of  the  teeth,  then  comes  spirit  and  drug  taking  as  a 
local  and  general  remedy. 

A  very  interesting  question  is  frequently  asked  concerning 
the  effects  of  tobacco  on  the  teeth  and  jaws.  Evidently  cigarette 
smoking  is  the  most  marked  form  of  tobacco  that  appears  to 
have  its  specific  effect  in  the  mouth,  and  persons  who  urge  the 
antiseptic  action  of  tobacco  find  it  very  difficult  to  substantiate 
their  claims  from  any  data  known  at  present.  x\nother  interesting 
fact  probably  has  some  influence  in  this  direction,  although  it 
cannot  be  very  clearly  made  out.  Thus  the  perversion  and  dimin- 
ution or  obliteration  of  the  sense  of  taste  follows  the  use  of  spir- 
its. Such  persons  show  abnormal  impulses  and  crave  for  acids, 
sugars,  salts,  and  irritant  condiments  which  influence  the  nerve 
terminals  of  the  teeth  and  the  mucous  membrane  of  the  mouth 
and  its  nutrition.  The  obliteration  of  the  sense  of  smell  is  another 
factor  encouraging  localization  of  acute  degeneration  of  the  teeth 
and  gums,  or  the  liver  and  kidneys. 

I  think  that  it  can  be  clearly  established  that  alcohol  taken  to 
great  excess,  either  continuously  or  at  intervals,  has  a  profound 
influence  on  the  teeth  and  gums.  In  paroxysms  followed  by  a 
distinct  free  interval  in  which  the  anesthetic  effects  pass  away 
and  a  degree  of  restoration  follows,  the  effects  are  less  prominent. 
In  the  continuous  use,  as  before  mentioned,  the  nutrition  and 
vigor  of  the  teeth  are  always  seriously  impaired.  Of  course,  there 
are  certain  distinct  pathologic  conditions  which  may  concentrate 
and  produce  more  serious  effects  in  some  particular  organ  of  the 
body  and  the  teeth  and  gums  may  be  one  of  these  locations. 
The  mucous  membrane  of  the  nose  and  throat  is  another.  The 
liver  and  heart  are  also  among  the  organs  that  register  these 
special  effects.  Occasionally  drug  and  spirit  takers  exhibit  great 
fragility  of  the  osseous  system  associated  with  degenerate  teeth. 


ORIGINAL  COMMUNICATIONS  295 

This  is  probably  owing  to  some  faults  in  the  diet  with  absence  of 
proper  mineral  matter  and  nutrition. 

An  observation  made  by  the  late  Dr.  Wright  some  years  ago, 
has  been  amply  confirmed  by  my  studies  ;  namely,  that  when  syph- 
ilis and  alcoholism  are  combined,  degeneration  of  the  teeth  and 
maxillaries  is  a  very  common  sequella.  Both  of  these  diseases  are 
toxic  and  the  teeth  and  jaws  should  always  be  examined  for  evi- 
dence of  their  influence. 

Another  observation  has  been  confirmed  in  many  ways  and  is 
this :  In  certain  families,  notably  those  who  began  with  alcohol 
degeneracy,  a  marked-  persistence  of  diseases  of  the  teeth  and 
jaws  are  noted,  extending  through  two  or  more  generations  and 
appearing  in  every  member  of  the  family.  I  have  seen  two  inci- 
dents of  this  in  which  a  great  grandfather  who  was  an  inebriate 
was  followed  by  a  numerous  family,  all  of  whom  had  defective 
and  diseased  teeth  in  early  and  middle  life.  This  degeneration 
continued  into  the  next  generation  and  was  most  marked.  There 
were  only  three  inebriates  in  a  family  of  twenty-six,  but  every  one 
had  degenerate  teeth. 

I  have  been  told  that  this  form  of  degeneration  is  sometimes 
seen  in  syphilitic  inheritance  and  no  doubt  this  is  true. 

I  conclude  these  observations  with  a  general  summary.  (1) 
Spirit  and  drug  taking  is  a  very  potent  cause  of  defective  teeth 
and  gums.  It  may  be  stated  that  a  large  percentage  of  degener- 
ation which  localize  in  the  teeth  and  gums  may  be  the  exciting 
causes  of  spirit  and  drug  taking.  The  increasing  prevalence  and 
demand  for  narcotic  drugs  indicates  low  vitality  of  which  the 
vigor  of  the  teeth  is  a  prominent  part,  and  lastly  a  study  and 
correction  of  the  injuries  or  beginnings  of  diseases  in  the  mouth 
may  be  the  removal  and  prevention  of  serious  drug  neurosis 
which  may  follow. 


296     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


BAtttth  KttxtUB 


HEART  FAILURE  TREATED  BY  MASSAGE  OF 
THE  HEART. 


The  readers  of  the  Therapeutic  Gazette  will  recall  that  on  a 
previous  occasion  we  drew  attention  to  this  subject  and  pointed 
out  that  the  term  massage  of  the  heart  was  applied  to  several 
widely  different  procedures.  Some  have  applied  it  to  massage  or 
kneading  of  the  precordium,  with  probably  no  direct  effect  upon 
the  heart,  but  only  a  reflex  irritation.  Others  have  practiced  so- 
called  massage  of  the  heart  through  the  diaphragm  during  the 
performance  of  an  abdominal  operation  when  cardiac  arrest  was 
threatened,  and  still  others  have  gone  So  far,  in  desperate  cases, 
as  to  incise  the  diaphragm,  pass  the  hand  through  the  opening, 
and  directly  massage  the  heart.  In  the  cases  to  which  we  re- 
ferred in  an  earlier  editorial  there  seemed  to  be  no  question  that 
such  measures  served  to  restore  cardiac  action.  Whether  the 
more  radical  method  last  cited  is  not  so  grave  as  to  be  virtually 
death-dealing  in  itself  is  a  question  for  debate,  although  reports 
show  that,  temporarily  at  least,  the  action  of  the  heart  is  re-estab- 
lished or  improved. 

For  these  reasons  we  have  noted  with  interest  an  article  by 
Molyneux  in  the  British  Medical  Journal  of  March  31,  1917,  in 
which  he  emphasized  the  interest  which  has  been  taken  of  late  in 
heart  massage,  when  the  massage  was  applied  through  the  dia- 
phragm in  a  patient  undergoing  operation.  He  is  also  familiar 
with  the  fact  that,  when  the  patient  has  collapsed  on  the  operating 
table  and  has  failed  to  respond  to  the  ordinary  stimuli,  massage 
through  the  diaphragm  has  been  practiced  with  advantage.  He 
advocates,  however,  not  permitting  undue  delay,  thinking  that 
desperate  conditions  should  be  met  by  desperate  measures,  and  he 
is  so  confident  of  the  value  of  the  method  that  he  even  discusses 
its  employment  in  collapse  complicating  operation  for  adenoids. 


SELECTED  ARTICLES  297 

Recognizing-  that  the  surgeon's  hands  are  not  sterile  and  that  he 
might  not  have  suitable  instruments  at  hand  for  abdominal  sec- 
tion, he  nevertheless  urges  that  delay  may  mean  the  loss  of  life 
and  that  the  chance  is  worth  taking. 

He  states  that  every  case  of  death  on  the  operating  table  that 
has  come  to  his  knowledge  has  been  employed,  and  that  it  is  very 
rare  to  hear  of  a  death  under  ether,  an  observation  which  is  in 
accord  with  that  of  the  entire  profession,  and  which  is  the  more 
interesting  since  in  chloroform  poisoning  the  heart  is  often  widely 
distended  and  fibrillating,  and  therefore  can  be  reasonably  ex- 
pected to  re-establish  its  contractions  if  by  gentle  compression  its 
cavities  can  be  emptied. 

The  cases  cited  by  Molyneux  are  as  follows : 

A  woman  of  sixty-three  was  sufficiently  optimistic  to  believe 
that  the  enlargement  of  her  abdomen  might  mean  her  first  preg- 
nancy, but  the  examination  showed  an  ovarian  tumor  of  great 
size  impeding  respiration.  Indeed,  Molyneux  describes  the  pa- 
tient as  a  shell  surrounding  a  tumor,  so  large  was  the  growth. 
The  pulse  was  irregular,  the  arteries  thickened,  and  there  was  a 
marked  aortic  systolic  murmur.  On  opening  the  abdomen  the 
tumor  was  removed^  after  having  been  aspirated,  and  the  pa- 
tient immediately  collapsed,  the  respiration  and  heart  both  stop- 
ping. Artificial  respiration  and  pituitary  extract  were  without 
effect.  The  right  hand  was  introduced  into  the  abdominal  incis- 
ion, the  left  hand  placed  over  the  heart,  and  the  heart  massaged 
by  a  series  of  rhythmic  squeezes  at  the  rate  of  forty  or  fifty  a 
minute,  the  right  hand  pressing  the  heart  through  the  diaphragm 
against  the  chest  wall,  this  being  re-in forced  by  pressure  on  the 
outside  of  the  chest  by  the  left  hand.  Molyneux  states  that  after 
a  short  time  the  heart  commenced  to  beat,  circulation  was  restored, 
and  the  patient  made  a  rapid  recovery.  Notwithstanding  his  pre- 
vious observation  in  regard  to  the  danger  of  chloroform,  ether 
was  the  anesthetic  in  this  case.  He  believes,  and  probably  cor- 
rectly, that  the  ecollapse  was  due  to  sudden  relief  of  intra-ab- 
dominal pressure,  the  tumor  being  so  large  that  it  took  two  peo- 
ple to  lift  it  off  the  table. 


298     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

His  second  case  was  that  of  a  man  with  appendicitis,  whose  age 
is  not  given.  As  soon  as  the  abdomen  was  opened  collapse  oc- 
curred. The  incision  was  rapidly  enlarged,  and  the  right  hand 
introduced  to  the  diaphragm  and  the  heart  felt  as  an  absolutely- 
flabby  organ  without  contraction.  Massage  of  the  heart  and 
artificial  respiration  were  at  once  commenced.  After  about  one 
minute  the  massage  was  stopped,  but  the  heart,  at  the  end  of  the 
second  minute,  began  to  beat  feebly.  Pituitan,-  extract  and  strych- 
nine were  injected,  and  after  about  five  minutes  the  patient's  con- 
dition improved  so  much  that  it  was  decided  to  complete  the  op- 
eration, as  the  appendix  was  distended  with  pus.  The  patient 
survived  the  operation,  was  sustained  by  continuous  enteroclysis 
of  normal  saline  containing  adrenalin,  and  made  a  good  recovery. 
In  this  case  the  anesthetic  used  was  a  mixture  of  chloroform  and 
ether  before  the  collapse  and  ether  subsequently. 

Further  information  in  regard  to  this  matter  is  g^ven  us  in  a 
report  made  by  MoUison  in  the  British  Journal  of  Children's 
Diseases  for  Januan,-  to  March,  1917.  Mollison  is  Surgeon  to  the 
Ear  and  Throat  Department  of  Guy's  Hospital,  London,  and  re- 
ports the  case  of  a  boy  of  six  years,  slightly  built,  but  healthy  in 
appearance,  who  had  a  histor}-  of  having  had  on  a  previous  occa- 
sion bronchitis  and  asthma,  and  from  whom  it  was  considered 
desirable  to  remove  the  tonsils  and  adenoids.  They  prepared  him 
in  the  usual  way  for  an  anesthetic,  a  purge  being  given  on  the 
day  before  the  operation  and  a  cup  of  milk  at  8  a.m.  on  the  morn- 
ing of  the  operation.  A  mixture  of  chloroform,  t\vo  parts,  and 
ether,  three  parts,  was  administered  on  an  open  mask.  The  pa- 
tient passed  speedily  into  unconsciousness  and  the  corneal  reflex 
was  never  lost.  The  left  tonsil  was  removed  successfully,  but 
while  the  right  was  being  removed  the  boy  struggled  slightly.  He 
was  then  turned  on  the  side  and  the  adenoids  curetted.  The  boy 
did  not  react  properly,  but  was  found  to  be  flaccid,  respiration 
ceased,  the  pupils  were  dilated,  and  the  corneal  reflexes  absent. 
The  head  was  lowered,  the  throat  cleared,  the  tongue  pulled  for- 
ward, and  artificial  respiration  by  Sylvester's  method  instituted. 
Although  the  air  entered  the  chest  quite  freely,  the  patient's  bad 
color  persisted.     Stimulants  were  administered,  hot  cloths  were 


SELECTED  ARTICLES  299 

applied  to  the  chest  and  abdomen,  brandy  and  ether  were  injected 
subcutaneously,  0.5  Cc.  of  pituitrin  injected  subcutaneously,  and 
another  0.5  Cc.  of  pituitrin  was  injected  through  the  chest-wall 
into  the  heart.  No  response  followed.  No  heart  sounds  could  be 
heard.  The  abdominal  walls  were  washed  with  ether  and  an  in- 
cision four  inches  long-  was  made  through  the  ensiform  cartilage 
to  just  above  the  umbilicus  in  the  middle  line,  but  there  was  no 
bleeding  from  the  sides  of  the  incision.  The  liver,  which  was  in- 
cidentally cut,  failed  to  bleed.  The  right  hand  was  introduced 
into  the  belly  to  feel  the  heart,  with  no  trace  of  movement.  With 
the  left  hand  on  the  chest  wall  and  the  fingers  of  the  right  hand 
behind  the  heart,  pressure  was  exerted  at  the  rate  of  about  ninety 
times  per  minute.  The  boy's  color  improved  and  his  pupils  con- 
tracted, but  there  was  no  attempt  at  heart  contraction.  After  a 
time  the  operator  became  tired,  and  an  assistant  continued  to 
massage  the  heart,  Mollison  injecting  nearly  1  cc.  of  pituitrin 
into  the  heart,  guiding  the  needle  through  the  chest-wall  between 
the  fingers  of  the  right  hand. 

Massage  was  now  renewed,  and  after  about  twenty  more 
squeezes  the  heart  suddenly  began  beating  strongly.  As  soon  as 
it  was  certain  that  the  heart  was  beating  well,  the  liver  was  su- 
tured and  the  abdominal  incision  closed.  It  was  estimated  that 
the  heart  had  ceased  beating  fifteen  or  twenty  minutes  before  its 
action  was  re-established.  The  whole  incident  lasted  from  1  p.  m., 
when  the  operation  began,  until  1.35  p.m.,  when  the  boy  was  re- 
turned to  the  ward.  On  his  return  to  the  ward  saline  infusions 
were  given  and  the  foot  of  the  bed  raised  considerably.  An  hour 
later  the  patient  became  restless,  his  limbs  were  rigid,  with  choreic 
movements,  and  the  intestines  escaped  from  the  wound,  requiring 
their  replacing  and  new  suturing.  The  boy  remained  more  or 
less  unconscious  for  a  period  of  seven  days,  and  for  some  days 
had  a  meningitic  cry,  which  on  one  occasion  was  almost  contin- 
uous for  thirty-six  hours ;  he  nevertheless  finally  began  to  improve, 
and  seventeen  days  after  the  operation  he  could  sit  up,  but  still 
had  incontinence  of  urine.  He  eventually  made  a  perfect  recovery 
and  left  the  hospital  about  six  weeks  after  the  operation. — The 
Therapeutic  Gazette. 


300     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


Extrartfi  from  i^omt  attb  3Fflrpign  SJournalja 


SURGICAL 


Experiences  in  Reconstruction  Surgery  of  the 
Extremities. 


In  the  September  International  Clinics  Babcock  calls  attention 
to  the  needless  sacrifice  which  is  often  made  of  extremities,  es- 
pecially the  hands,  which  can  be  restored  to  a  fair  degree  of  use- 
fulness by  conservative  surgery.  The  article  is  very  profusely  il- 
lustrated. He  goes  into  considerable  detail  in  showing  how  a 
badly  injured  limb  may  be  saved,  either  partially  or  completely. 
The  article  which  does  not  lend  itself  readily  to  condensation, 
should  be  consulted  by  all  interested  in  surgery.  It  is  especially 
valuable  for  those  entering  the  military  service  where  many  of 
the  problems  it  deals  with  will  be  encountered  frequently. 


Sarcoma  of  the  Rectum. 


This  is  a  very  rare  condition,  but  when  it  does  occur,  the  growth 
arises  in  the  connective  tissue  around  the  bowel,  though  it  is  very 
difficult  to  say  in  which  particular  element  of  the  connective  tis- 
sue the  growth  started.  The  sarcoma  may  arise  in  the  pelvic 
fascia  and  secondarily  invade  the  bowel ;  again  it  arises  from  the 
pelvic  bones.  However,  sarcoma  proper  of  the  bowel  arises 
in  the  submucous  connective  tissue  and  grows  out  into  the  lumen 
of  the  bowel,  lifting  the  mucous  membrane  before  it  so  that  the 
early  signs,  pus  and  blood,  of  carcinoma  appear  very  late  in  sar- 
coma. When  once  fairly  started  or  irritated,  the  sarcoma  grows 
very  rapidly. 

In  a  case  seen  lately  by  the  writer,  the  patient,  a  woman,  no- 
ticed a  lump  just  within  the  anal  opening.  It  enlarged  rapidly 
bringing  her  to  the  doctor.     The  lump  was  three  months  ago  in- 


EXTRACTS  FROM  JOURNALS  301 

side  the  anus,  now  there  was  a  nodule  the  size  of  a  marble  pro- 
truding. It  seemed  to  arise  at  the  anorectal  junction,  was  beneath 
the  mucous  membrane  and  extended  anteriorly  between  the  bowel 
and  vagina,  and  laterally  into  the  left  ischio-rectal  fossa.  When 
first  seen  it  was  smooth,  non-pedunculated,  firm,  and  appeared  to 
be  a  fibroma.  The  irritation  due  to  the  protrusion  of  the  tumor 
through  the  sphincter,  however,  caused  such  an  increase  in  the 
rapidity  of  the  tumor's  growth  that  at  operation  a  week  later,  it 
was  half  again  as  large  and  had  begun  to  ulcerate.  Microscopical 
examination  showed  it  to  be  a  small  round-celled  sarcoma,  the 
most  malignant  type,  as  ^hown  in  this  case  by  recurrence  three 
weeks  after  operation. — Pacific  Medical  Journal. 


Dangers  of  Tonsillectomy. 


A  news  item  following  the  death  of  Mr.  Henry  Field  is  ex- 
pressed in  these  words :  "Mr.  Field  had  been  ill  in  the  Presbyte- 
rian Hospital  for  the  last  two  months.  He  first  submitted  to  an 
operation  for  the  removal  of  his  tonsils  and  later  an  abscess  of 
the  lung  was  discovered."  Putting  two  and  two  together  the  as- 
sumption that  the  lung  abscess  was  a  result  of  the  tonsil  operation, 
seems  not  unreasonable. 

Recent  medical  literature  shows  this  accident  to  have  occurred 
repeatedly  under  similar  conditions.  Tonsillectomy,  or  the  com- 
plete removal  of  the  tonsils,  as  distinguished  from  less  dangerous, 
less  radical,  and  less  fashionable  tonsil  operations,  is  a  modern 
stunt.  It  is  quite  justified  in  exceptional  cases.  But  the  orgy  into 
which  it  has  degenerated  within  recent  years,  is  little  short  of 
criminal.  It  is  a  dangerous  operation.  Serious  hemorrhages  are 
of  daily  occurrence.  The  rapid  development  of  tuberculosis 
through  liberation  of  tubercle  bacilli  into  the  blood  stream  after 
tonsillectomy  has  been  frequently  noted.  Instead  of  curing  some 
rheumatics,  their  ailment  has  been  lashed  into  furious  activity. 

The  medical  press  has  repeatedly  issued  warnings  of  caution. 
To  call  attention  to  the  situation  in  the  public  press  seems  to  me, 
therefore,  neither  untimely  nor  indiscreet.    On  the  contrary,  I  con- 


302     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

sider  it  a  public  duty.  A  generation  ago  one  of  the  popular  oper- 
ations among  gynecologists  was  Battey's  operation,  or  the  "re- 
moval of  the  ovaries  in  order  to  eliminate  their  physiological  in- 
fluence" (Gould's  Dictionary  of  Medicine).  Women  were  spayed 
on  the  slightest  provocation.  No  surgeon  of  today  would  dare 
expose  himself  to  the  contumely  and  derision  which  would  pursue 
him  at  the  performance  of  that  one-time  elegant  and  remunera- 
tive feat.  So  will  it  also  be  when  the  debauch  of  the  indiscrim- 
inate butchery  of  the  tonsils  will  have  run  its  course. — Medical 
Review  of  Reviews. 


The  Treatment  of  Wounds  of  the  Knee- Joint. 


I.  S.  Novis  (Lancet,  July  7,  1917),  in  the  treatment  of  wounds 
of  the  knee-joint,  lays  stress  on  the  necessity  for  free  drainage  of 
the  posterior  pouches.  If  this  is  done  at  a  reasonably  early  stage, 
the  large  majority  of  cases  will  recover  with  a  useful  limb  and 
many  will  recover  with  a  fair  range  of  movement.  Complete 
ankylosis  will  by  no  means  necessarily  follow.  Novis  is  convinced 
that  too  extended  a  trial  of  milder  methods  of  treatment  has  led 
to  the  loss  of  many  limbs  and  lives  which  might  have  been  saved, 
had  free  drainage  been  established  earlier.  Moreover,  free  incis- 
ions into  the  posterior  pouches  will  do  all  that  can  be  hoped  for 
from  freely  opening  up  the  joint  by  cutting  through  the  ligamen- 
tum  patellae  and  other  ligaments  and  will  leave  an  infinitely  more 
useful  limb. — International  Journal  of  Surgery. 


Results  of  Surgical  Treatment  of  Gastric  Ulcer. 


Balfour  (Surgery,  Gynecology  and  Obstetrics,  June,  1917),  bas- 
ing his  conclusions  upon  677  gastric  ulcers  operatively  demon- 
strated in  the  Mayo  clinic  during  the  past  ten  years,  emphasizes 
the  following  facts : 

For  ulcers  at  the  pylorus,  posterior  gastroenterostomy  is  the 
operation  of  choice  in  the  poor  surgical  risk,  for  although  pylor- 
ectomy  is  followed  by  better  results,  the  operative  mortality  is  dis- 


EXTRACTS  FROM  JOURNALS  303 

tinctly  higher.    The  cautery  is  a  useful  adjunct  in  selected  cases. 

For  ulcers  on  the  lesser  curvature,  cautery  by  the  method  de- 
scribed in  a  previous  paper  and  gastroenterostomy  is  the  opera- 
tion of  choice. 

Local  excision  alone  of  such  ulcers  is  inadequate,  32  per  cent 
of  patients  so  operated  on  requiring  further  operative  treatment, 
viz.,  gastroenterostomy. 

Sleeve  or  segmental  resection,  especially  in  large  high  ulcers 
and  hour-glass  contraction,  in  suitable  cases  is  not  only  a  rela- 
tively safe  operation  but  has  been  followed  by  good  results. 

The  lowest  operative  mortality  in  the  more  common  operations 
was  associated  with  cautery  and  posterior  gastroenterostomy. 

Ulcers  on  the  posterior  wall  are  associated  with  the  highest  op- 
erative risk,  while  those  at  the  pylorus  are  of  least  risk. — The 
Therapeutic  Ga::ette. 


Intestinal  Obstruction. 


The  correctness  of  the  views  held  by  eminent  surgeons  is  em- 
phasized by  Jackson.  It  is  evident  that  surgical  relief  of  obstruc- 
tion is  the  only  final  salvation  for  life,  and  should  be  instituted 
early  before  the  patient  has  already  absorbed  a  lethal  dose  of 
poison.  Delay  is  only  excusable  then  for  practically  all  acute 
abdominal  crises  which  may  in  any  way  simulate  obstruction  are 
themselves  likewise  surgical  conditions.  The  only  excuse  for  the 
responsible  physician  is  the  refusal  of  patient  to  accept  his  advice. 
The  lost  body  fluid  should  be  replaced  by  proctoclysis  and  hypo- 
dermoclysis,  both  before  and  after  operation.  Thus  fluids  are  re- 
placed, toxins  diluted,  elimination  increased  and  acidosis  neutral- 
ized. Jackson  favors  the  direct  surgical  drainage  of  the  high 
intestinal  area,  advocated  by  AIcKenna.  The  principle  is,  a  quick 
enterostomy  high  in  the  jejunum  as  the  sole  primary  operation. 
Six  to  eight  weeks  later,  with  the  patient  in  good  condition,  the 
obstructed  and  damaged  area  is  successfully  resected. — Journal 
of  the  American  Medical  Asso. 


304     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

MEDICAL 


Goitre. 


An  Analysis  of  125  cases  with  a  Note  on  the  Treatment,  by  Leigh 
F.  Watson,  M.D.,  Chicago. 


The  author  reviews  the  records  of  25  goitre  patients  consider- 
ing the  cause,  age  at  onset,  and  effect  of  previous  operations  in 
certain  cases.  He  illustrates  by  tables  and  degree  of  enlargement, 
and  reports  the  results  following  quinin  and  urea  injection. 

In  43  per  cent  no  exciting  cause  could  be  elicited;  in  the  re- 
maining 57  per  cent  the  onset  could  be  ascribed  to  a  definite  ex- 
citing cause.  Of  the  125  cases,  15  per  cent  was  caused  by  worry; 
parturition  was  responsible  for  11  per  cent,  and  in  9  per  cent  the 
condition  was  due  to  puberty.  Twenty  per  cent  gave  a  family 
history  of  goitre  and  11  per  cent  of  nervousness;  19  per  cent  had 
had  tonsilitis.  Forty-five  per  cent  of  the  exophthalmic  patients 
first  noted  the  goitre  eight  years  before  examination  at  the  av- 
erage age  of  34  years,  and  the  symptoms  developed  at  the  age  of 
40.  Fifty  per  cent  gave  a  history  of  acute  onset,  two  years  be- 
fore coming  under  observation  at  the  average  age  of  29  years. 
Sixty  per  cent  of  the  nonexophthalmic  patients  observed  that  they 
developed  more  marked  symptoms  of  intoxication  as  the  goitre 
became  more  chronic. 

Before  coming  under  treatment,  five  ophthalmic  patients  had 
had  ligation  of  the  superior  thyroid  arteries  with  temporary  re- 
lief; four  had  had  partial  thyroidectomies  without  permanent 
benefit;  three  had  had  pelvic  operations  without  lessening  the 
hyperthyroidism ;  the  condition  of  one  was  aggravated  by  a  pan- 
hysterectomy ;  and  one  had  had  a  tonsillectomy  six  months  before 
without  influencing  the  severity  of  the  exopthalmic  symptoms. 
Enlargement  usually  begins  in  the  right  lobe,  sometimes  in  the 
isthmus  and  least  frequently  in  the  left  lobe.  In  95  per  cent  of 
the  exophthalmic  patients  of  this  group  both  lobes  and  isthmus 
were  involved  before  the  goitre  became  exophthalmic.  A  majority 


EXTRACTS  FROM  JOURNALS  305 

of  the  patients  noticed  increasing  symptoms  of  intoxication  as  the 
goitre  became  more  chronic,  gradually  involving  both  lobes  and 
isthmus.  Eeighteen  per  cent  of  the  mildly  toxic  patients  became 
exophthalmic  after  an  average  period  of  five  years.  This  study  in- 
dicates that  both  nontoxic  and  toxic  goitre  occur  later  in  life  in 
nongoitrous  localities  than  in  sections  where  the  disease  is  more 
prevalent. 

The  following  tables  show  the  results  after  quinin  and  urea 
injections: 

Effect  of  the  Injection  on  Symptoms — 

"Relieved  Imp.  Not  Imp. 

Exophthalmic 85   (aver.  4  mos.)     15  0 

Nonexophthalmic 84   (aver.  2  mos.)      10  6 

Effect  of  the  Injections  on  Goitre — 

Cured  Reduced     Not  Red. 

Exopthalmic 80  (aver.  4  mos.)      15  5 

Nonexophthalmic 75   (aver.  4  mos.)      12  13 

Two  patients  suffering  with  severe  toxic  goitre  with  exophthal- 
mos of  several  years  duration  received  only  slight  benefit ;  later  a 
lobectomy  was  done  without  additional  relief.  Four  exophthalmic 
patients  were  pregnant  two  to  four  months.  Relief  from  hyper- 
thyroidism followed  the  injection  and  they  went  to  term  without 
recurrence  and  had  normal  deliveries.  The  number  of  patients 
cured  is  highest  in  the  group  of  those  who  came  for  treatment 
early  in  the  disease ;  the  benefit  received  by  those  who  came  later 
was  in  proportion  to  the  degree  of  damage  done  the  circulatory 
and  nervous  systems.  A  goitre  that  had  once  disappeared  has 
never  recurred.  A  majority  of  the  patients  in  this  group  have 
been  under  observation  for  two  to  four  yearrs.  The  quinin  and 
urea  injection  has  limitations  the  same  as  any  other  treatment  for 
goitre  and  can  be  employed  only  in  selected  cases.  The  treatment 
of  the  exophthalmic  type  in  young  adults  is  very  difficult,  and 
should  be  attempted  only  under  the  most  favorable  circumstances. 
If  the  best  results  are  to  be  secured,  hyperthyroidal  patients  must 
have  at  least  a  year  of  mental  and  physical  rest  after  treatment. — 
New  York  Medical  Journal. 


306     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 
Functional  Tests  in  Chronic  Nephritis. 


Christian  discussed  in  the  International  Climes  the  various  tests 
to  determine  the  functional  capacity  of  the  kidney,  normally  the 
phthalien  output,  blood  urea,  nitrogen,  index  of  urea,  excretion 
and  specific  gravity  of  urine. 

The  last  mentioned  is  a  simple  means  of  determining  the  func- 
tional cavity  of  the  kidney.  The  kidney  normally  accommodates 
itself  to  different  kinds  of  urea  complexes  by  excreting  a  more  or 
less  concentrated  urine,  a  urine  which  pretty  closely  parallels  the 
fluid  intake.  If,  however,  the  kidney  is  injured  it  does  not  ac- 
commodate itself  so  promptly  that  curves  representing  the 
specific  gravity  taken  every  two  hours  instead  of  showing  marked 
variations  flatten  out  in  proportion  as  the  kidney  is  diseased. 

Christian  believes  that  the  functional  tests  are  useful  in  deter- 
mining prognosis,  and,  to  a  certain  extent  treatment,  and  in  some 
cases  diagnosis,  when  there  is  a  question  of  early  nephritis,  but 
they  are  mainly  helpful  from  the  point  of  view  of  prognosis. 


Heart  Murmurs. 


Laubry's  remarks  are  addressed  to  the  practitioner^  not  the 
specialist.  He  reiterates  that  the  special  moment  during  the  heart 
cycle  at  which  the  murmur  appears,  and  its  duration,  are  the  main 
points  for  estimation  of  its  clinical  significance.  The  important 
thing  is  to  locate  the  murmur  in  time  rather  than  in  space;  its 
seat  is  of  less  moment.  Vaquez  declares  that  the  heart  should 
never  be  examined  first  with  the  stethoscope;  this  should  be  re- 
served till  later  to  determine  the  exact  point  where  the  murmur 
sounds  loudest.  The  first  phase  should  be  determined  not  by  the 
pulse  but  by  the  tactile  sensation  of  the  apex  beat  which  accom- 
panies the  sound.  When  a  diastolic  murmur  commences  with 
the  second  phase  or  immediately  afterward,  finishes  immediately 
before  the  first  phase,  and  fills  the  whole  of  the  long  pause,  it  is 
always  organic,  it  occurs  only  with  aortic  insufficiency,  the  sound 
is  a  rumbling,  not  a  mumur.  When  the  murmur  occupies  the  en- 
tire systole,  commencing  with  the  first  phase  and  stopping  with 


EXTRACTS  FROM  JOURNALS  307 

the  second,  it  is  always  a  sign  of  valvular  disease,  but  if  there  is 
even  a  brief  space  free  from  it  at  the  middle  or  end  of  the  short 
pause,  then  the  murmur  can  be  recognized  as  not  only  inorganic 
but  it  can  be  located  outside  of  the  heart,  in  the  precardiac  sheet 
of  the  lung.  If  the  free  interval  is  at  the  beginning  of  the  short 
pause,  then  it  may  be  organic  notwithstanding  the  integrity  of  the 
first  sound.  A  murmur  of  inorganic  origin  may  be  encountered 
with  tachycardia,  in  which  case  exact  localization  in  time  is  out  of 
the  question.  The  site  of  the  murmur  is  of  little  importance  with 
a  diastolic  murmur  but  is  important  with  the  systolic.  In  the  re- 
gion of  the  base  and  of  the  middle  of  the  heart,  at  about  the  third 
interspace  and  the  fourth  rib,  every  dubious  murmur  not  decidedly 
filling  the  entire  pause  may  be  regarded  as  inorganic,  as  also  every 
murmur  at  the  base  not  followed  by  a  diastolic  murmur.  In  the 
apex  region,  if  there  is  any  doubt,  prolonged  response,  influence 
of  change  of  position  or  of  pressure  on  the  eyeball  may  modify 
conditions  so  that  the  murmur  may  be  better  understood.  Of 
course  the  above  applies  only  to  dubious  murmurs.  With  actual 
organic  disease  there  is  no  chance  for  doubt.  The  practitioner 
should  practice  to  locate  the  murmur  at  its  special  point  in  the 
time  cycle.  When  certain  of  this,  he  can  fit  the  knowledge  thus 
gained  into  the  whole  train  of  symptoms  and  the  history  of  the 
case,  and  all  may  become  clear.  The  murmur  symptom  should 
be  analyzed  first  of  all. — The  Journal  of  the  Am.  Med.  Asso. 


OBSTETRICAL 


Status  Epilepticus  in  the  Pregnant. 


Albeck's  experience  has  convinced  him  that  status  epilepticus 
in  pregnant  or  parturient  women  is  not  so  exceptional  as  would 
appear  from  the  records^  but  it  is  often  mistaken  for  eclampsia. 
Differentiation  is  particularly  difficult  when  the  epileptic  seizures 
are  accompanied  by  albuminuria  and  edema,  as  in  his  three  cases. 
The  fact  that  the  patient  is  known  to  be  an  epileptic  or  that  the 
convulsions  have  recurred  at  previous  pregnancies,  speaks  for  the 


308      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

epileptic  nature  of  the  trouble,  as  eclampsia,  he  says,  as  good  as 
never  occurs  twice  in  the  same  individual.  The  blood  pressure 
may  also  aid  in  differentiation ;  a  normal  or  nearly  normal  blood 
pressure  is  not  found  in  eclampsia.  In  five  cases  on  record  of 
status  epilepticus  in  pregnant  or  parturient  women  all  terminated 
fatally,  but  Jardine  has  reported  a  case  at  the  eight  month  and  the 
woman  recovered  after  cesarean  section.  Albeck  systematically 
interrupted  the  pregnancy  in  his  three  cases,  by  instrumental  dila- 
tation or  cesarean  section,  and  all  the  women  recovered.  He  thinks 
that  a  latent  or  frank  tendency  to  epilepsy  is  roused  by  some  preg- 
nancy intoxication.  He  has  had  151  cases  of  what  he  calls  eclamp- 
sisms  among  3,000  pregnant  women ;  in  one  case  it  was  pro- 
nounced in  an  epileptic  woman  for  a  few  weeks  before  delivery 
but  yet  status  epilepticus  did  not  develop,  and  a  living  child  was 
delivered  by  section  at  term.  This  patient  had  been  given  potas- 
sium bromid  regularly  from  the  first  symptoms.  None  of  the 
women  thus  treated  developed  status  epilepticus,  but  when  it  was 
already  installed,  he  did  not  venture  to  allow  the  pregnancy  to 
continue  but  interrupted  it  at  once.  The  outcome  in  his  three 
cases  testifies  to  the  wisdom  of  this  method  of  treating  status 
epilepticus  in  a  woman  suffering  from  pregnancy  intoxication. — 
The  Journal  of  the  American  Med.  Asso. 


Full  Term  Ectopic  Gestation  Retained  Eighteen  Yeasr. 


A  woman,  aged  46,  consulted  Peterson  for  an  abdominal  tumor 
which  had  existed  for  eighteen  years.  Five  years  after  marriage 
there  was  cessation  of  menstruation,  the  usual  morning  sickness 
and  enlargement  of  the  breasts.  There  was  a  gradual  increase 
in  the  size  of  the  abdomen  until  at  the  nine  month  she  was  as 
large  as  a  woman  at  term.  She  felt  life  at  the  fifth  month  but 
does  not  remember  at  what  time  movement  ceased.  She  thought 
she  was  pregnant  but  never  had  any  labor  pains.  Shortly  after 
the  cessation  of  menstruation  for  nine  months,  she  began  to  flow 
regularly  again.  She  remained  the  same  size,  that  is,  the  size 
of  a  woman  at  term,  for  two  years,  then  gradually  became  smaller. 
For  the  past  six  years  her  abdomen  has  been  of  about  the  same 


EXTRACTS  FROM  JOURNALS  309 

size.  During-  the  past  year  she  has  not  been  feeling  well  and  has 
lost  10  or  15  pounds.  The  tumor  rose  rather  abruptly  from  the 
pubes,  the  highest  point  being  half  way  between  this  point  and  the 
umbilicus.  The  growth  was  symmetrical,  smooth,  somewhat 
tender  and  distinctly  fluctuating.  It  was  fixed  and  apparently 
quite  densely  adherent  to  the  parietal  peritoneum.  Posterior  to 
the  cervix  could  be  felt  an  irregular,  tender  mass  about  the  size 
of  a  small  hen's  egg  apparently  attached  to  the  tumor  which 
could  be  made  out  as  a  cystic  mass  by  palpation  through  the 
culdesac.  It  was  impossible  to  palpate  the  appendages.  On  cut- 
ting through  the  abdominal  wall,  the  fluctuating  sac  was  found 
densely  adherent  to  the  parietal  peritoneum,  omentum  and  por- 
tions of  the  intestine.  During  the  enucleation  of  the  sac  the 
latter  was  nicked  in  one  portion,  giving  exit  to  an  oily  fluid  of 
about  the  consistency  and  color  of  pea  soup.  When  the  sac  was 
cut  open  it  was  found  to  contain  the  greater  portion  of  a  fetal 
skeleton. — The  Journal  of  the  American  Med.  Asso. 


Abdominal  Caesarean  Section. 


Abdominal  Caesarean  section  has  an  established  place  in  surgi- 
cal obstetrics.  Where  absolutely  indicated  for  mechanical  rea- 
sons its  performance  should  be  early  decided  upon  and  patient  not 
subjected  to  test  of  labor. 

Its  success  will  vary  inversely  with  chance  of  previous  infec- 
tion. 

Eclampsia  is  not  inself  an  indication  for  Caesarean  section,  but 
an  obstetrical  condition  which  precludes  rapid  and  safe  delivery 
through  the  natural  passage  is  an  indication  for  Caesarean  section 
in  eclampsia. 

It  is  preeminently  important  that  Caesarean  section,  when  indi- 
cated, be  done  early  in  eclampsia  before  the  narrow  margin  of 
safety  is  effaced  by  repeated  infection-inviting  examinations  and 
attempts  at  delivery.  This  should  not  be  forgotten  when  the 
uterus  has  been  thus  emptied  the  treatment  is  not  complete.  Only 
the  "toxo-genetic"  focus  has  been  removed  and  the  further  elabor- 
ation of  the  eclampsia  producing  poison  stopped.    The  patient  will 


310     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

recover  or  succumb  according  to  whether  or  not  she  is  already 
hopelessly  saturated  with  the  kidney  and  liver  necrosing  poisons 
of  eclampsia. 

Placenta  prsevia  and  premature  separation  of  normally  situ- 
ated placenta  do  not  demand  Csesarean  section  if  the  sofe  parts 
are  prepared  for  rapid  natural  delivery.  In  short,  any  obstetric 
condition  that  may  confront  us,  whether  it  be  a  problem  in  me- 
chanics, as  an  impacted  shoulder  presentation,  or  urgent  pathol- 
ogy, as  toxemia;  hemorrhage,  or  poorly  compensating  heart  le- 
sion, should  be  indications  for  Csesarean  section  if  it  appears  that 
this  operation  offers  best  chance  of  life  to  mother  and  child. — 
The  Virginia  Medical  Se mi-Monthly. 


Smallpox  in  Utero. 


A  woman,  pregnant  about  three  months,  was  sleeping  in  the 
same  bed  with  her  husband  who  was  found  to  have  smallpox. 
She  was  immediately  removed  to  another  room  and  she  and  her 
two  children  and  a  man  and  woman  who  were  taking  care  of  the 
family  were  successfully  vaccinated.  The  woman  had  a  typical 
reaction  to  the  vaccine  virus.  The  quarantine  was  raised  in  six 
weeks.  One  month  afterward  Roth  well  was  called  to  see  her. 
On  examination  he  could  find  no  signs  of  life  in  the  fetus  and 
the  OS  uteri  was  dilated  about  the  size  of  a  quarter.  The  vagina 
was  aseptically  packed  with  gauze  and  at  6  o'clock  next  morning 
a  six  or  six  and  a  half  months  mummified  fetus  was  expelled. 
Life  must  have  been  extinct  for  some  time,  as  the  abdomen  was 
discolored  and  distended,  and  the  abdominal  muscles  and  integu- 
ment were  very  thin  and  fragile.  What  was  most  noticeable, 
however,  was  the  presence  of  round,  yellow,  slightly  pitted  scars 
about  the  size  of  the  end  of  a  lead  pencil,  distributed  over  the 
whole  surface  of  the  body,  where  the  scabs  had  become  detached 
in  utero.  Also  the  vesicles  and  pustules  that  invariably  accompany 
a  severe  case  of  variola  vera  were  present.  The  mother  had  never 
a  sign  of  a  papule,  vesicle  or  pustule  but  she  has  a  normal  vaccin- 
ation scar. — The  Journal  of  the  American  Med.  Asso. 


EDITORIALS  311 


iEhttortal 


PUBLISHER'S  NOTICE— The  Journal  is  published  in  monthly  numbers  of 
48  pages  at  |1.00  a  year,  to  be  always  paid  in  advance. 

All  bills  for  advertisements  to  be  paid  quarterly,  after  the  first  insertion  of 
the  quarter. 

Business  communications,  remittances  by  mail,  either  by  money  order, 
draft,  or  registered  letter,  should  be  addressed  to  the  Business  manager,  C. 
S.  Briggs,  M.D.,  corner  Summer  and  Union  Streets,  Nashville,  Tenn. 

All  communications  for  the  Journal,  books  for  review,  exchanges,  etc., 
should  be  addressed  to  the  Editor. 


Standing  Behind  Our  Soldiers. 


You  are  undertaking  a  great  duty.  The  heart  of  the  whole 
country  is  with  you.  Everything  that  you  do  will  be  watched  with 
the  deepest  interest  and  with  the  deepest  solicitude  not  only  by 
those  who  are  near  and  dear  to  you  but  by  the  whole  Nation  be- 
sides, for  this  great  war  draws  us  all  together.  >;=**. — 
From  President  Wilson's  Address  to  the  soldiers  of  the  National 
Army. 

If  the  heart  of  the  whole  country  is  with  our  soldiers  of  the 
National  Army,  and  it  is  believed  that  it  is,  the  money  of  the 
Nation  will  be  back  of  them.  The  Liberty  Loan  is  to  be  used  to 
arm,  equip,  and  maintain  our  soldiers,  to  prepare  them  for  the 
conflict  in  France,  and  make  them  as  effective  and  powerful  as 
possible,  and  safeguard  them  in  every  way  possible.  In  addition, 
it  will  be  used  to  give  them  life  and  indemnity  insurance  and  pro- 
vide for  their  dependents.  The  uses  of  the  Liberty  Loan  appeal 
to  every  patriotic  American,  for  it  is  used  for  our  soldiers  and 
sailors  and  the  principles  which  they  uphold,  which  the  heart  of 
the  whole  country  is  with. 

The  foundation  of  our  great  country  is  liberty ;  its  superstruc- 
ture, peace. — William  McKinley. 


312     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

Stenographers  and  Typewriters  Wanted. 
Men  and  Women. 


The  United  States  Government  is  in  urgent  need  of  thousands 
of  typewriter  operators  and  stenographers  and  typewriters.  All 
who  pass  examinations  for  the  departments  and  offices  at  Wash- 
ington, D.  C,  are  assured  of  certification  for  appointment.  It  is 
the  manifest  duty  of  citizens  with  this  special  knowledge  to  use  it 
at  this  time  where  it  will  be  of  most  value  to  the  government. 
Women  especially  are  urged  to  undertake  this  office  work.  Those 
who  have  not  the  required  training  are  encouraged  to  undergo 
instruction  at  once. 

Examinations  for  the  Departmental  Service  are  held  every 
Tuesday,  in  450  of  the  principal  cities  of  the  United  States,  and 
applications  may  be  filed  with  the  Commission  at  Washington, 
D.  C,  at  any  time. 

The  entrance  salary  ranges  from  $1,000  to  $1,200  a  year.  Ad- 
vancement of  capable  employes  to  higher  salaries  is  reasonably 
rapid. 

Applicants  must  have  reached  their  eighteenth  birthday  on  the 
date  of  the  examination. 

For  full  information  in  regard  to  the  scope  and  character  of 
the  examination  and  for  application  blanks  address  the  U.  S.  Civil 
Service  Commission,  Washington,  D.  C,  or  the  Secretary  of  the 
U.  S.  Civil  Service  Board  of  Examiners  at  Boston,  Mass. ;  New 
York,  N.  Y. ;  Philadelphia,  Pa.;  Atlanta,  Ga. ;  Cincinnati,  Ohio; 
Chicago,  111. ;  St.  Paul,  Minn. ;  St.  Louis,  Mo. ;  New  Orleans,  La. ; 
Seattle,  Wash. ;  San  Francisco,  Cal. ;  Honolulu,  Hawaii,  or  San 
Juan,  Porto  Rico. 

John  A.  McIlhenny, 
Pres.  U.  S.  Civil  Service  Commission,  Washington,  D.  C. 


One  Phase  of  Home  Defense. 


Washington,  Sept.  .  "Protect  the  defective  children,  pro- 
vide for  their  training  and  proper  care,  and  you  will  lessen  the 
burden  of  dependency  and  delinquency."    This  is  the  gist  of  the 


EDITORIALS  313 

advice  contained  in  a  new  report  on  IMental  Defectives  issued  by 
the  Children's  Bureau  of  the  U.  S.  Department  of  Labor,  and 
appearing  with  special  timeliness  now  that  war  conditions  may 
tend  to  make  more  serious  the  problem  of  delinquent  and  de- 
pendent children. 

The  report  is  based  on  a  study  of  the  social  conditions  of  212 
mental  defectives  in  New  Castle  County,  Delaware.  A  total  of, 
175,  or  more  than  four-fifths  of  these,  were  in  need  of  public 
supervision  or  institutional  care  because  of  bad  home  conditions, 
physical  helplessness,  or  pronounced  anti-social  tendencies,  and 
only  twelve  of  them  were  provided  for  in  an  institution  adapted 
to  their  care.  Twent>'=-six  of  the  defective  children  were  in  in- 
dustrial schools  for  delinquent  children,  and  of  these  the  report 
says : 

"Institutions  for  the  care  of  delinquent  children  are  greatly 
handicapped  by  the  presence  of  defectives,  since  they  require 
special  attention  and  exert  a  bad  influence  over  the  normal  chil- 
dren. After  a  short  period  of  residence  these  defectives  are  re- 
turned to  the  community  without  sufficient  supervision." 

Other  defective  children  with  delinquency  records  were  at  large 
in  the  community;  in  all,  98  of  the  212  defectives  studied  were 
delinquent  or  immoral  or  difficult  to  control. 

The  report  suggests  that,  while  any  program  for  the  care  of 
mental  defectives  must  have  as  its  central  feature  suitable  insti- 
tutional provision  offering  training  or  custodial  care  according  to 
the  needs  of  the  individual,  other  activities  are  equally  essential. 
It  is  pointed  out,  for  example,  that  institutional  care  is  not  nec- 
essary for  all  mentally  defective  children,  for,  contrary  to  the  pop- 
ular impression,  it  is  found  that  there  are  certain  types  who  safely 
can  remain  at  home  provided  they  have  the  attention  and  study 
which  they  deserve.  However,  special  provision  should  be  made 
for  their  safety,  care,  and  education,  and  out-patient  work  of  an 
institution  for  the  feeble-minded,  in  co-operation  with  schools, 
social  agencies,  and  families,  is  referred  to  as  a  new  and  impor- 
tant method  of  providing  in  the  most  humane  possible  way  for 
such  children. 


314     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

The  possibilities  of  industrial  training  by  which  certain  types 
of  defectives  may  gradually  become  in  part  self-supporting  and 
the  importance  of  providing  facilities  for  mental  examination  and 
diagnosis  of  doubtful  cases  are  also  brought  out  in  the  report. 


New  York,  September  20,  1917. 

Dr.  C.  S.  Briggs,  Nashville,  Tenn. : 

My  Dear  Editor — To  further  the  interest  of  the  Surgeon  Gen- 
eral's office  in  securing  a  sufficient  number  of  applicants  for  com- 
mission in  the  Medical  Reserve  Corps,  it  has  been  suggested  that 
the  profession  at  large  be  given  an  idea  of  the  real  pleasure  as 
well  as  profit  that  those  in  medical  officer's  training  camps  enjoy. 

Believing  that  you  must  have  one  or  many  of  your  friends  in 
these  camps,  won't  you  write  to  them  asking  for  a  letter  for  pub- 
lication, expressing  in  a  general  way,  the  pleasure  as  well  as  the 
character  of  work  carried  on? 

It  seems  to  be  the  assumption  in  certain  minds  that  Medical 
Reserve  Officers  have  rank  but  no  standing  or  proper  recognition 
of  rank  with  officers  of  other  branches  of  the  service  or  that  the 
average  regular  army  officer  looks  upon  the  Medical  Reserve  Of- 
ficer as  an  inferior  personage  all  of  which  I  personally  know  not 
to  be  the  case. 

Officers  of  the  Medical  Corps  of  the  United  States  Army,  who 
are  detailed  instructors,  have  but  one  ambition  and  that  is  to  im- 
part as  agreeably,  readily  and  thoroughly  as  possible,  their  knowl- 
edge of  military  medical  work  to  the  Reserve  Corps  Officers. 

So  that  you  may  fully  understand  the  character  of  letter  that 
will  be  of  the  greatest  service,  I  would  refer  you  to  the  communi- 
cation from  Lieut.  Guedel  and  Lieut.  Moore,  appearing  in  the 
September  issue  of  the  American  Journal  of  Surgery. 

It  is  absolutely  necessary  that  any  letter  sent  from  a  training 
camp,  should  be  first  submitted  to  and  passed  by  the  commandant 
of  the  camp. 

In  these  times  when  the  interest  of  the  medical  profession  is 
centered  almost  solely  upon  war  news  and  information  of  a  med- 
ical military  character,  you  can  unmeasurably  add  to  the  attrac- 


EDITORIALS  315 

tiveness  of  your  journal  to  your  readers,  by  letters  of  this  kind 
and  other  information  relating-  to  the  Medical  Reserve  Officer  and 
his  work.     I  am,  Cordially  yours, 

J.  MacDonald,  78.,  M.D., 

Secretary-  Treasurer. 


Mortality  Caused  by  Automobiles  and  by  Other 
Vehicles  Compared. 


Another  condition  developed  by  this  study  is  the  fact  that  as  far 
as  the  industrial  population  is  concerned,  more  deaths  are  caused 
by  automobiles  than  b}-  surface  cars,  subway  cars,  subway  trains, 
elevated  trains,  bicycles  and  horse-drawn  vehicles  combined.  In- 
deed, in  1916  the  756  deaths  caused  by  automobiles  approaches 
very  closely  the  799  persons  insured  in  the  company  killed  on 
steam  railroads. 

The  figures  for  Metropolitan  policy-holders,  it  must  be  borne 
in  mind,  represent,  almost  exclusively,  pedestrians,  rather  than 
those  who  ride  in  the  machines.  This  is  particularly  true  of  the 
children.  A  large  part  of  this  mortality,  it  is  evident,  is  due  to 
reckless  driving  and  to  the  heedlessness  of  children  to  the  dangers 
to  which  they  expose  themselves.  But  whatever  be  the  cause,  it 
is  clear  from  these  figures  that  the  automobile  is  an  important 
agency  of  death  and  that  its  control  by  the  communities  must  be 
immediate  and  thorough  if  improvement  is  to  be  made. 


Weekly  Health  Index. 


Washington.  D.  C,  October  11,  1917.— As  a  health  index  the 
Bureau  of  the  Census  will  publish  each  week  mortality  reports 
from  the  largest  cities  in  the  United  State. 

There  will  be  given  for  each  city  the  total  number  of  deaths 
reported  (still-births  excluded),  the  death  rate,  the  number  of 
deaths  under  one  year  of  age,  and  the  proportion  of  infant  deaths 
to  total  deaths. 

Where  the  data  are  obtainable  for  the  previous  five  years,  av- 
erages for  the  corresponding  weeks  will  be  given  for  each  city. 


316     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

These  totals,  rates,  and  percentages  will  permit  valuable  com- 
parisons and  will  serve  as  a  ready  health  index  for  health  officers 
and  others.  As  weekly  figures  always  fluctuate  widely,  caution 
must  be  used  in  their  interpretation.  Health  experts,  however, 
will  immediately  appreciate  the  value  of  this  new  compilation. 


Action  of  National  Association. 


Several  important  matters  were  acted  upon  at  the  recent  meeting 
of  the  Executive  Committee  of  The  National  Association  for  the 
Study  and  Prevention  of  Tuberculosis,  and  are  of  interest  to  the 
membership  of  the  Association  and  to  other  readers  of  the  Bulletin 

The  following  resolution  was  adopted  placing  the  Association 
on  record  as  endorsing  the  principle  of  separation  allowances  to 
be  provided  by  federal  legislation. 

Resolved,  That  the  Executive  Committee  of  The  National  As- 
sociation for  the  Study  and  Prevention  of  Tuberculosis  endorses 
the  principle  of  separation  allowances  to  be  provided  by  federal 
legislation  and  of  compensation  for  the  injuries,  sickness  and 
death  resulting  from  war,  and  that  a  committee  be  appointed  to 
further  federal  legislation  to  the  above  end. 

A  bill  embodying  these  features  is  now  being  introduced  in 
Congress. 

The  attitude  of  the  Association  at  the  Cincinnati  meeting  in 
urging  physicians  and  nurses  who  have  specialized  training  in 
tuberculosis  to  utilize  that  training  where  it  will  be  of  most  ad- 
vantage was  further  endorsed  by  another  special  resolution 
adopted  by  the  committee,  which  reads  as  follows : 

Resolved,  That  The  National  Association  for  the  Study  and 
Prevention  of  Tuberculosis  through  its  Executive  Committee 
strongly  urges  the  physicians  who  are  experienced  in  the  diag- 
nosis and  treatment  of  tuberculosis  in  all  parts  of  the  country  to 
co-operate  with  the  federal  medical  authorities  and  in  every  way 
that  may  be  suggested,  and  without  regard  to  commissions. 

The  executive  secretary  was  also  authorized  by  resolution  to 
confer  with  Col.  G.  E.  Bushnell  of  the  surgeon  general's  office  of 


EDITORIALS  317 

the  War  Department  with  reference  to  referring  cases  of  tuber- 
culosis discovered  in  the  examination  of  recruits. 

The  employment  of  arrested  cases  of  tuberculosis  in  light  posi- 
tions in  outdoor  work  in  order  to  release  individuals  for  more 
vigorous  service  was  discussed  and  it  was  decided  that  the  execu- 
tive office  should  communicate  with  State  associations,  federal 
authorities  and  other  groups  asking  with  regard  to  positions  such 
as  those  of  watchmen,  rural  delivery  postmen,  etc.,  and  suggest- 
ing that  these  positions  be  thrown  open  to  arrested  cases  of  tuber- 
culosis. It  was  also  sugested  that  legislation  that  would  prevent 
such  employment  be  eliminated.  The  executive  office  was  also 
requested  to  look  into  the  question  of  governmental  regulations 
preventing  the  employment  of  arrested  cases  of  tuberculosis. 

The  prevalence  of  tuberculosis  among  Roman  Catholic  sister- 
hoods, nuns,  teachers,  etc.,  and  the  lack  of  hygienic  teaching  in 
parochial  schools  was  discussed  and  the  executive  office  was  in- 
structed to  confer  with  certain  leading  Catholic  clergy  and  lay- 
men relative  to  such  measures  as  might  be  acceptable  to  the 
Church. 


Obituary. 


Dr.  Thos.  E.  Elliston  died  at  his  country  home  near  the  Her- 
mitage October  13th,  from  a  complication  of  diseases.  Dr.  Ellis- 
ton  was  a  prominent  practitioner  of  medicine  in  this  city  for 
nearly  forty  years  and  enjoyed  a  large  and  exacting  practice  in 
the  section  in  which  he  lived.  He  specialized  in  obstetrics  and 
had  a  record  of  nearly  twenty-five  hundred  deliveries.  Dr.  Ellis- 
ton  was  an  excellent  physician,  a  careful,  conscientious  practi- 
tioner and  a  most  estimable,  upright,  and  honorable  gentleman. 


318      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


Sfiit^his  unh  Innk  '^otxttB 


Progressive  Medicine — A  Quarterly  Digest  of  Advances,  Discoveries  and 
Improvements  in  the  Medical  and  Surgical  Sciences.  Edited  by  Hobart 
Amory  Hare,  M.D.,  Professor  of  Therapeutics,  Alateria  Medica  and 
Diagnosis  in  the  Jefferson  Medical  College,  Philadelphia.  Assisted  by 
Leighton  F.  Appleman,  M.D.,  Instructor  in  Therapeutics,  Jefferson  Med- 
ical College,  Philadelphia,  September  1,  1917.  Owners  and  Publishers, 
Lea  and  Febiger,  Philadelphia,  New  York.     Six  dollars  per  annum. 

This  number  of  this  ever  welcome  quarterly  publication,  with 
its  full  quota  of  good  things  for  the  progressive  up-to-date  phy- 
sician, has  been  received  ,and  we  take  great  pleasure  in  again  call- 
ing the  attention  of  the  medical  profession  to  its  great  value  as 
an  educator  and  a  true  indicator  of  the  advances  and  discoveries 
of  the  most  recent  date  in  the  medical  and  surgical  sciences.  It 
represents  the  cream  of  serial  medical  literature.  It  is  the  wheat 
removed  from  the  chaff.  By  means  of  this  quarterly  we  can  see 
at  almost  a  glance  what  is  occurring  in  the  medical  world  just  as 
the  scouting  aviator  sees  what  movements  are  made  by  the  enemy 
on  the  battlefield.  The  editors  have  shown  wise  discrimination 
in  the  selection  of  the  following  well  known  authorities  as  con- 
tributors to  this  number.  These  are :  Edward  P.  Davis,  M.D., 
William  Ewart,  M.D.,  F.  R.  C.  P.,  William  S.  Goetheil,  M.D.,  and 
Wililam  G.  Spiller,  M.D.  The  subjects  treated  of  in  this  number 
are  as  follows :  "Diseases  of  the  Heart,  Lungs  and  Blood  Ves- 
sels" ;  "Dermatology  and  Syphilis" ;  "Obstetrics" ;  "Diseases  of 
the  Nervous  System"  and  Index.  We  can  not  say  too  much  in 
praise  of  this  excellent  quarterly  publication.  It  is  a  library  with- 
in itself  and  it  presents  the  newest  work  in  every  branch  of  medi- 
cine. In  subscribing  to  this  publication  the  practitioner  can  make 
no  mistake  for  it  is  all  that  it  purports  to  be  and  will  be  a  great 
help  to  every  practitioner  who  desires  to  keep  in  the  front  ranks 
of  the  medical  profession. 


PUBLISHERS'  DEPARTMENT  319 


Publtfilirr  s  i^partm^nt 


Notwithstanding  the  large  number  of  Hypophosphates  on  the  market, 
it  is  quite  difficult  to  obtain  a  uniform  and  reliable  syrup.  "Robinson's" 
is  a  highly  elegant  preparation,  and  possesses  an  advantage  over  some 
others,  in  that  it  holds  the  various  salts,  including  iron,  quinin'j  and  strych- 
nine, etc.,  in  perfect  solution,  and  is  not  liable  to  the  formation  of  fungous 
growths.     (See  advertisement  in  this  issue.) 


Urinary  Antisepsis. 


In  the  opinion  of  many  practitioners  sanmetto  offers  the  nearest  ap- 
proach to  the  ideal  inhibitor  to  bacterial  growth.  It  is  not  only  non-toxic 
and  non-irritating  but  rather  soothing  to  the  urinary  tract,  while  not 
strongly  antiseptic  yet  sufficiently  bacteriostatic  for  common  routine  cases. 
It  is  largely  excreted  by  the  kidneys.  In  prostatic  cases  it  tends  to  relieve 
incontinence,  clears  up  the  urine,  and  is  useful  as  soother  before  and  fol- 
lowing instrumentation.  It  is  of  positive  value  in  urethritis  and  cystic  con- 
ditions. It  is  never  accompaned  by  the  untoward  conditions  so  often  fol- 
lowing the  use  of  more  powerful  germicidal  and  bactericidal  antiseptics. 
Sanmetto  is  safe. 


Cod  Liver  Oil  in  the  Debilitated. 


The  reason  why  ordinary  cod  liver  oil  is  not  adapted  to  most  debilitated 
cases  is  to  be  found  in  the  fact  that  the  impaired  gastric  function  quickly 
gives  way  under  the  extra  burden  of  digesting  the  fatty  substance  con- 
tained in  the  oil. 

The  objection  to  the  plain  oil  is  obviated  if  a  palatable  preparation,  such 
as  Cord.  Ext.  01.  Alorrhuae  Comp.   (Hagee),  is  employed. 

Not  only  is  Cord.  Ext.  01.  Morrhuae  Comp.  (Hagee)  palatable  and 
tolerated  for  indefinite  periods,  but  further  still  it  offers  the  debilitated 
patient  the  every  essential  property  of  the  plain  oil.  It  is  everything  that 
plain  cod  liver  oil  is  except  disagreeable. 


A  Reliable  Anodyne. 


In  casting  about  for  a  reliable  anodyne  for  routine  purposes,  the  physi- 
cian can  make  no  better  choice  than  Papine  (Battle).  The  reasons  are 
that  it  is  a  purified  opium  product  of  definitely  uniform  strength,  carefully 
prepared  and  productive  of  a  minimum  of  after-effects. 

Papine  (Battle)  is  of  particular  advantage  in  the  case  of  women  or 
neurotics,  who  must  be  protected  from  the  psychical  impression  offered  by 
a  hypodermic  injection  of  morphine. 

Whenever  an   anodyne  is  needed   Papine    (Battle)    will  be   found  to 
serve  to  the  utmost. 


320      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 
Just  What  Pasadyne  (Daniel)   Is. 


To  disabuse  the  minds  of  those  who  may  think  that  Pasadyne  (Daniel) 
is  a  mixture  of  various  sleep-producing  agents,  we  wish  to  emphasize  the 
fact  that  Pasadyne  (Daniel)  is  nothing  but  a  pure,  concentrated  tincture 
of  passiflora  incarnata.  The  name  "Pasadyne"  is  merely  a  distinctive 
name  used  to  distinguish  our  passiflora  product  from  other  similar  prep- 
arations but  of  inferior  therapeutic  worth.  We  have  specialized  for  more 
than  forty  years  in  making  Pasadyne  (Daniel).  Hence,  it  ought  to  be  a 
superior  product.  It  is  a  safe  and  dependable  nerve  sedative.  It  has  no 
concern  with  the  Harrison  Act.  Write  for  sample  bottle  to  John  B.  Daniel, 
Inc.,  Atlanta,  Georgia. 


THE  OBSTIPATIOX-STATUS-AUTOTOXEMIA  SYNDROME  is 
complex  in  its  etiology  as  well  as  in  its  nosology.  Anything  that  inter- 
feres with  the  calibre  of  the  gut,  or  with  the  free  passage  of  intestinal 
contents  through  the  tube,  results  in  a  difficult  passage  of  the  bowel  con- 
tents along  the  intestinal  canal — Obstipation. 

This  may  be  ptosis,  or  displacement  of  the  gut  at  some  point,  a  kink, 
abnormal  sagging  of  suspensory  structures,  or  dislocation  of  some  part 
of  the  tube.  This,  together  with  abnormal  dryness  of  lack  of  lubricating 
mucus,  due  to  disturbance  of  the  intestinal  mucous  glands,  results  in  stag- 
nation of  the  current,  stopping  in  many  instances,  a  damming  back  of  the 
current — Stasis. 

As  a  result  of  these  influences,  opportunity  is  given  for  increased  bac- 
terial or  chemical  action,  the  production  of  an  abnormal  amount  of  toxins 
of  unusual  virulence,  irritation  and  disturbance  of  the  filtering  or  protec- 
tive action  of  the  mucous  membrane  and  resulting  absorption  of  increased 
quantities  of  poisonous  material — autotoxemia. 

As  a  result  of  so  many  factors  working  more  or  less  interdependently, 
is  the  establishment  of  the  S3mdrome — a  complex  group  of  many  symp- 
toms, that  may  simulate  almost  any  disease  or  diseased  condition  met  with 
in  medicine. 

Furthermore,  these  conditions,  if  allowed  to  go  uncorrected,  may  and 
often  do,  aggravate  or  cause  serious,  even  fatal  disease. 

The  ideal  treatment  for  such  conditions  is  lubrication.  The  ideal  intes- 
tinal lubricant  is  INTEROL  because  it  comes  close  to  Nature's  own  lubri- 
cant— mucus — in  that  it  lubricates  without  stimulation,  irritation  or  ener- 
vation. Being  non-absorbable,  it  lubricates  "all  the  way."  On  account  of 
its  characteristic  lubricating  body  it  efficiently  mixes,  spreads  and  clings 
in  the  intestinal  tract,  and  unless  too  much  is  administered  it  does  not 
separate  from  the  feces  it  lubricates  and  keeps  soft.  It  does  not  "ooze," — 
"per  se." 


NASHVILLE  JOURNAL 

OF 

MEDICINE  AND    SURGERY 

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

Vol.  CXI.  NOVEMBER,  1917.  No.  11 

Original  Qlommuntratinna 

THE  ULTIMATE  RESULTS  OF  THE  OPERATIVE  TREATMENT 
OF  MAMMARY  CANCER.* 


BY  DR.  HANS  LINDENBERG, 

Assistant  Physician  of  the  Clinic. 


(Translated  by  W.  T.  Briggs,  M.D.) 

Less  than  fifty  years  have  passed  since  members  of  the  medical 
profession  ceased  to  consider  cancer  an  absolutely  incurable  disease. 
During  this  time  the  surgery  of  cancer  has  become  more  and  more 
potent.  With  the  discovery  of  the  X-rays  and  radium  of  compara- 
tively recent  date  the  surgeon  has  found,  it  seems,  a  powerful  ally; 
but  the  results  of  "ray  therapy"  are  still  recent  and  some  time  must 
have  passed  before  we  have  proof  of  its  power.  In  our  clinic  the 
X-rays  have  also  been  used  as  an  adjunct  to  the  operative  treatment, 
but  up  to  the  present  time  I  have  not  been  able  to  calculate  their 
effect  in  the  statistics  of  our  results  in  mammary  carcinoma.  During 
the  time  under  consideration  only  a  few  X-ray  treatments  have  been 
given  and  these,  with  what  is  now  considered  unsatisfactory  appa- 
ratus. For  this  reason  my  statistics  are  based  entirely  on  the  opera- 
tive treatment. 

The  183  cases  considered  in  this  article  were  operated  during  the 
years  1901-1910  at  the  surgical  clinic  at  Rostock  under  Prof.  Muller, 
who  took  charge  of  the  clinic  in  the  fall  of  1911.  So  the  latter  date 
was  chosen  as  the  starting  point.     Cases  operated  during  the  last 


•From  the  Surgical  Clinic  of  the  University  of  Rostock — Geh.  Medizinalrat 
Prof.  W.  Muller. 


322     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

three  years  were  not  included,  since  three  years  is  the  shortest  time 
without  recurrence  required  before  the  case  can  be  rated  as  cured. 
In  this  way  a  better  comparison  can  be  made,  since  most  modern 
statistics  are  based  on  the  three-year  period.  Results  should  deter- 
mine whether  this  time  limit  is  long  enough. 

I  will  not  discuss  here  the  origin  of  mammary  carcinoma  nor  can- 
cer in  general.  However,  I  would  like  to  take  up  in  a  general  way 
the  previous  histories  of  our  patients  in  order  to  see  whether  they 
give  us  any  clue  to  the  more  frequent  cause  of  origin  of  mammary 
cancer  or  perhaps  some  exciting  cause. 

First  of  all  comes  the  question  of  heredity.  In  only  twenty  cases 
was  there  a  history  of  cancer  in  the  family.  However,  it  must  be 
taken  into  consideration  that  on  account  of  the  prevailing  dread  of 
cancer  in  this  country  any  such  questioning  must  be  conducted  with 
the  greatest  tact,  because  of  the  psychic  effect  on  the  patient.  Often- 
times neither  the  patient  nor  her  relatives  know  the  true  nature  of 
the  trouble.  Therefore,  the  small  percentage  (10  per  cent)  of  car- 
cinoma cases  in  the  immediate  family  can  make  no  claim  to  com- 
pleteness. On  some  such  basis  I  suppose  can  be  explained  the  very 
different  statements  in  the  literature.  While  Rosenstein  finds  a  he- 
reditary influence  in  3.1  per  cent  of  his  cases;  Gebele  and  Winiwarter 
5  per  cent;  Horner  and  Poulsen  in  Copenhagen  found  17  per  cent; 
Wunderli  in  St.  Gallen  20  per  cent.  So  statistics  do  not  answer  this 
question  satisfactorily. 

It  is  easier  for  the  surgeon  to  question  in  regard  to  injury  than  in 
regard  to  heredity.  But  even  here  we  find  an  obstacle  to  accuracy, 
since  most  people  do  not  associate  cause  and  effect  unless  there  is 
some  external  manifestation.  Consequently  the  effect  of  trauma  is 
probably  undervalued  by  most  physicians. 

Horner  alone  attributes  great  significance  to  it  in  the  later  devel- 
opment of  cancer.  In  11  or  6  per  cent  of  our  cases  the  patients 
thought  the  trouble  was  caused  by  a  punch  or  blow.  The  statements 
of  other  investigators  varied  between  2.2  per  cent  (Hildebrand)  and 
44  per  cent  (Williams).  About  10  per  cent  was  the  average.  Wil- 
liams, however,  emphasized  the  fact  that  a  single  so-called  acute 
trauma  has  little  relationship  to  later  carcinoma.  It  is  easier  to 
suppose  that  chronic  irritation  favors  the  development  of  cancer.  I 
favor  this  view  mvself. 


ORIGINAL  COMMUNICATIONS 


323 

Figures  help  but  little  in  an  attempt  to  determine  the  influence  of 
marriage  on  the  later  development  of  caneer.     Among  women  of 
middle  age  the  married  preponderate  in  number.     So  it  is  not  as- 
omshmg  ■   most  authors  find  the  married  in  much  greater  numbers, 
«^e  percentages  varying  from  60  (Poulsen)    to  90   (Winiwarter) 
Hea  h  must  be  excepted,  since  he  observed  the  disease  oftener  in  the 
single.    Our  figures  show  84.4  per  cent  married.    How  many  of  these 
had  borne  children    I  am  sorry  to  say,  could  not  be  definitely  de- 
termmed  from  the  histories. 

th.^"l^V'K^*\^.''.''"-  *^'''  ^^^  ^^^"  ^  P^^^i«"^  inflammation  of 
the  gland;  but  Wimwarters  records  give  21.05  per  cent;  Cebele's  20 
per  cent;  Sprengel  s  30  per  cent;  Oldekopfs  9  per  cent,  and  Hilde- 
brand  s  even  41  per  cent.  So  mastitis,  perhaps  because  of  the  scar 
Ussue,  must  not  be  entirely  forgotten  as  a  predisposing  cause  of 

Age  is  a  very  important  factor  whenever  cancer  is  concerned  In 
mammary  cancer  there  is  no  exception  to  the  rule  that  cancer  before 
toy  xs  extremely  rare.  Our  youngest  patient  was  twenty-two  years 
old.  As  might  have  been  supposed,  our  four  patients  under  thirty 
confirmed  the  experience  that  carcinoma  in  young  individuals  is 
usuaHy  very  malignant.  Three  died  before  one'year'had  passed  the 
fourth  m  the  second  year  after  operation.  According  to  age  our 
cases  were  divided  as  follows:  ^ 

Under  20 

Between   20-30 

Between   30-40   ,q 

Between  40-45   26 

Between  45-50  ^^ 

Between   50-55   27 

Between   55-60 .g 

Between  60-65   " 23 

Between  65-70  .g 

Over  70  \. 

6 

The  percentage  of  cases  in  the  decade  40-50,  especially  the  sec 
end  half,  was  much  greater  than  in  the  other  decades.    Sev  n  y  sTx 

r.Tted     r         *'  -^'"""r™'  '"  ""''  "°'=  -  «  eases  h'w 
not  noted.    In  my  opinion  it  depends  but  little  on  the  exact  time  the 


324     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

menses  cease,  since  the  changes  in  the  female  body  during  this  tran- 
sitional period  often  extend  over  a  period  of  several  years.  It  is 
only  natural  that  in  a  period  of  total  change  latent  cells  should  re- 
ceive a  stimulus  to  grow  and  thus  lead  to  neoplastic  formation. 
Ninety-three,  or  a  little  more  than  half  of  our  cases,  were  affected 
between  the  ages  of  40-55  years.  But  older  patients  furnish  a  large 
percentage.  A  rapid  decline  in  incidence  after  70,  such  as  Sprengel 
mentions,  was  not  noted  in  our  material.  From  the  above  we  can 
conclude  that  mammary  cancer  is  generally  a  disease  of  middle 
life  and  old  age.  This  conclusion  coincides  with  that  of  most  au- 
thorities excepting  Sprengel  and  Volkmann,  who  think  50-60  the 
commonest  age.  During  this  time  we  treated  three  cases  of  cancer 
of  the  breast  in  men;  one  was  50  years  old,  two  in  the  sixties.  I 
have  included  these  in  the  records,  since  as  single  cases  they  would 
possess  no  statistical  value. 

Unfortunately,  the  time  between  the  discovery  of  the  tumor  by 
the  patient  and  the  operation,  could  be  determined  accurately  in 
only  a  few  cases.  This  question  is  too  dependent  on  the  degree  of 
personal  attention  e.  g.  depends  on  the  care  each  devoted  to  her 
body.  An  educated  woman,  who  has  heard  of  breast  tumors  and 
their  malignancy,  will  note  the  presence  of  tumor  sooner  than  the 
working  woman.  Cancer  cases  in  the  family  or  among  friends  put 
them  more  on  their  guard.  In  regard  to  the  time  the  tumor  had 
been  present  our  patients  answered  as  follows: 

Less  than  2  weeks 10 

From  2-4  weeks  16 

From  1-2  months  22 

From  2-3  months  16 

From  3-6  months  27 

From  6-12  months 44 

From  1-2   years  22 

From  2-3   years  9 

From  3-4  years   4 

Over  4  years  13 

At  least  1-3  of  the  patients  came  to  the  clinic  within  three  months 
after  the  discovery  of  the  tumor,  almost  3-4  within  one  year.  As  a 
rule  the  patients  have  come  to  the  clinic  relatively  early. 


ORIGINAL  COMMUNICATIONS  325 

What  were  the  resuhs  of  examination  on  entrance?  Like  Stein- 
thal  and  others  I  would  like  to  separate  the  cases  into  four  divisions 
according  to  the  clinical  findings.  In  group  I,  I  place  slow-growing 
neoplasms  which  are  freely  movable  with  no  glandular  metastases. 
Group  2  includes  those  in  whom  the  tumor  has  advanced  a  step 
further,  although  the  axillary  glands  are  not  palpable,  neither  is 
there  extension  of  the  growth  to  the  skin  or  muscles  nor  is  there  any 
fixation.  Group  3,  those  cases  with  extension  of  the  growth  to  the 
skin  or  to  the  muscles  or  to  both,  with  metastases  to  the  glands. 

Group  4,  cases  with  supraclavicular  extension.  As  often  men- 
tioned in  the  literature,  so  in  our  cases,  there  was  not  always  a  defi- 
nite relationship  between  the  clinical  condition  of  the  axillary  glands 
and  the  microscopic  findings.  The  axillary  glands  were  palpable 
in  twenty-eight  cases  in  which  there  was  no  cancerous  invasion  dem- 
onstrated, while  in  four  cases  cancer  was  found  in  glands  which 
had  not  been  palpated.  I  will  discuss  the  microscopic  findings  in 
the  different  groups,  since  this  is  decisive  in  the  prognosis.  Our  cases 
were  divided  as  follows 

Group  1    35 

Group  2    81 

Group  3   53 

Group  4   14 

According  to  the  time  from  the  discovery  of  the  tumor  to  the  op- 
eration the  different  groups  show  the  following: 

Group 
12  3  4 

Before  1  month  had  passed.. ..8  cases  17  cases  1  cases  0  cases 
Before  3  months  had  passed  8  cases  21  cases  5  cases  4  cases 
Before  1  year  had  passed. ...15  cases  29  cases  23  cases  4  cases 
After  1  year  had  passed 4  cases     14  cases     24  cases     6  cases 

In  two  cases  the  tumor  had  been  present  more  than  four  years. 

In  group  1  the  number  of  early  cases,  e.  g.  those  operated  within 
three  months  after  discovery  of  the  tumor,  was  45.7  per  cent;  in 
group  2,  46.9  per  cent;  in  group  3,  11.3  per  cent,  and  in  group  4, 
28.6  per  cent.  From  these  figures  we  must  conclude  that  time  alone 
has  comparatively  little  relationship  to  the  stage  of  the  neoplastic 


26      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERV 

growth.  For  on  an  average  the  cases  in  group  1  had  tumors  which 
had  not  been  present  longer  than  those  in  group  2,  as  a  matter  o^ 
fact  the  percentage  of  relatively  early  discovered  tumors  is  greatest 
in  group  2.  Group  1  is  unique.  The  tumors  of  patients  in  this 
group  seem  to  have  but  little  tendency  to  spread.  They  are  unique 
also  as  we  shall  later  see  in  the  operative  end-results.  Both  breasts 
were  simultaneously  affected  in  two  cases.  Both  cases  died  of  cancer 
within  one  year. 

Let  us  now  compare  these  clinical  findings  with  the  pathologic- 
histological  diagnoses  which  were  made  either  during  or  after  the 
operation.  All  of  the  tumors  were  examined  in  the  pathological  lab- 
oratory in  Rostock.  Almost  all  the  carcinomata  had  originated  in 
the  glandular  tissue;  they  represent  the  different  types  of  solid  car- 
cinoma. We  had  only  one  case  of  the  rare  squamous  cell  carcino- 
ma (Langhans).    The  following  diagnoses  were  made: 

Carcinoma,  Simplex  and  Schirrhus 1 

Scirrhus    40  cases 

Adenocarcinoma 31  cases 

Medullary  Carcinoma  4  cases 

Colloid   Carcinoma   5  cases 

In  four  tumors  of  different  types  were  found  in  different  parts  of 
the  same  breast  and  should  be  looked  upon  as  transitional  types. 
They  were: 

Carcinoma,  Sixplex  and  Schirrhus 1 

Medullary  Carcinoma  and  Scirrhus 2 

Adenocarcinoma  and  Scirrhus 1 

In  one  case  of  scirrhus  the  examination  of  the  axillary  glands 
gave  same  result  as  in  carcinoma  simplex.  Finally  one  of  the  cases 
in  which  both  breasts  were  affected,  showed  carcinoma  simplex  of 
the  right  and  scirrhus  of  the  left.  In  these  cases  there  was  not  a 
single  instance  where  there  was  a  benign  as  well  as  a  malignant  tu- 
mor in  the  same  or  other  breast.  More  than  half  of  our  cases  had 
carcinoma  simplex,  2-9  scirrhus  and  1-6  adenocarcinoma.  So  these 
are  the  types  with  which  we  usually  have  to  deal.  With  us  the  me- 
dullary and  colloid  types  were  very  rare.  I  am  sorry  to  say  I  found 
but  little  in  the  literature  about  the  distribution  according  to  the 
pathological   findings.     Most  articles  discuss  only  the  proportion 


ORIGINAL  COMMUNICATIONS 


327 


of  cures  to  the  total  number  of  cancers.  Wunderli's  statistics  agree 
for  the  most  part  with  mine.  They  show  a  somewhat  greater  per- 
centage of  carcinoma  simplex  but  a  much  smaller  percentage  of 
adenocarcinoma  than  mine.  In  36  cases  Hildebrand  found  scir- 
rhus  11  times  and  colloid  cancer  5  times.  He  makes  no  distinction 
between  adenocarcinoma  and  carcinoma  simplex.  Salomon  in  1913 
made  a  report  on  the  material  of  Bier's  clinic  from  a  pathologic- 
histologic  standpoint.  His  figures  agree  with  mine  except  that  scir- 
rhus  formed  a  much  smaller  percentage.  Leech  found  an  unusu- 
ally large  percentage  (54)  of  scirrhus.  I  wish  to  illustrate  the  re- 
lationship of  the  clinical  to  the  histologic  findings,  and  both  of  these 
to  the  duration  of  the  disease  by  the  following  tables: 


STAGE  1—35 


u 


Time 


U 


u 


so.;:; 


en  .  U 

Before  14  days  3 

14-30   days  5 

1-2    months    1       4 

2-3    months    1     .- 

3-6  months  4 

6m — 1   year   1      2 

1-2    years    1     — . 

2-3    years    2 

3-4   years    

Longer    

4    20 


u 


1     1 


STAGE  3—53 


Before  14  days  

14-30   days   

1-2    months    

2-3  months  1 

3-6  months  1 

6m — 1    year   4 

1-2   years    3 

2-3    years    

3-4    years    

Longer  2 

11 


3 
5 
8 
6 
2 
2 
3 
30 


STAGE  2—81 

53 

X 

u 

v 

• 

>-. 

tc 

Q. 

C  1 

u 

3 

o 

e 

en 

o 

1 

'B 
'o 

3 

'7a 
o 

-1 

CA) 

u 

< 

u 

H 

3 

3 

3 

1 

7 

5 

2 

8 

10 

7 

5 

4 

2 

i 

12 

1 

2 

3 

1 

i 

7 

9 

3 

1 

4 

1 

1 

10 

6 

6 

11 

2 

19 

2 

4 

2 

6 

2 

i 

1 

1 
3 

i 

1 

2 
4 

22 

39 

11 

3 

3 

STAGE  4- 

14 

i 

i 

1 

5 

1 

i 

6 

1 

14 

1 

2 

1 

10 

3 

i 

2 

7 



(Neither  Table  3  or  4  are  correct  in  the  original  article  since  the 
tabulated  total  does  not  agree  with  the  total  given  for  these  groups.) 


328     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

These  tables  show  that  to  the  first  clinical  stage  belong: 

29  per  cent  of  the  cases  of  Adenocarcinoma. 
21  per  cent  of  the  cases  of  Carcinoma  Simplex. 
10  per  cent  of  the  cases  of  Scirrhus. 
25  per  cent  of  the  cases  of  Medullary  carcinoma. 
20  per  cent  of  the  cases  of  Colloid  carcinoma. 

The  last  figures  illustrate  well  the  uncertainty  of  using  the  per- 
centage basis  when  small  numbers  are  used.  For  instance,  with  five 
colloid  and  4  medullary  cancers,  each  of  which  came  to  us  with  the 
trouble  not  far  advanced  so  far  as  could  be  determined  clinically, 
my  figures  show  respectively  20  and  25  per  cent,  which  would  lead 
to  wrong  conclusions  unless  the  total  number  of  cases  were  consid- 
ered. We  will  refer  again  to  the  question  of  percentage  statistics 
based  on  insufficient  material  in  the  discussion  of  results.  Compared 
to  the  other  tumors,  adenocarcinoma  seems  to  show  less  tendency  to 
spread  rapidly.  Halstead  and  Salomon  also  emphasize  this  fact. 
This  corresponds  with  its  anatomical  structure  inasmuch  as  it  re- 
sembles most  the  normal  structure  of  the  point  of  origin — the  gland- 
ular acinus.  In  the  first  group,  scirrhus  shows  the  lowest  percentage 
of  the  different  types,  55  per  cent  in  the  second,  27.5  per  cent  in  the 
third,  and  7.5  per  cent  in  the  fourth.  Carcinoma  simplex  was  pres- 
ent in  40.5  per  cent  in  the  second  group,  31  per  cent  in  the  third,  7.5 
per  cent  in  the  fourth.  According  to  their  tendency  to  spread  the 
principle  types  of  carcinoma  in  the  first  group  can  be  arranged  as 
follows: 

1.  Adenocarcinoma.  2.  Carcinoma  Simplex.  3.  Scirrhus. 
In  the  second  group  this  arrangement  is  changed  in  that  scirrhus 
stands  first,  carcinoma  simplex  second  and  adenocarcinoma  third. 
Taken  all  in  all  one  gets  the  impression  that  any  type  of  cancer  may 
progress  rapidly  or  slowly.  Especially  is  this  so  in  regard  to  scir- 
rhus, which  is  rightly  considered  a  slowly  growing  type  of  cancer. 

The  tumor  was  located  98  times  in  the  left  breast,  83  times  in  the 
right  breast  and  twice  in  both.  In  detail  the  position  of  the  tumor 
was  as  follows: 


ORIGINAL  COMMUNICATIONS  329 

Right  Left 

Upper  outer  quadrant  25  times 40  times 

Upper  inner  quadrant  9  times 11  times 

Lower  outer  quadrant 10  times.... 5  times 

Lower  inner  quadrant  2  times 1  time 

Upper  half   8  times 11  times 

Lower  half  2  times 1  time 

Outer  half  4  times 5  times 

.Inner  half  1  time 2  times 

"Central  part  13  times 2  timse 

Entire  breast  11  times 8  times 

The  left  breast  was  oftener  affected  than  the  right,  but  not  to  such 
a  degree  that  any  special  conclusions  can  be  drawn.  Against  mak- 
ing such  a  mistake  Winiwater  has  already  cautioned  in  a  review  of 
the  statistics  of  Henning,  who  noted  that  the  right  breast  was  oftener 
affected  and  attributed  this  to  the  more  severe  injuries  to  which 
this  breast  is  subject.  Winiwarter  and  other  authorities  all  agree 
that  the  upper  outer  quadrant  is  the  most  common  site  of  tumor, 
and  for  the  most  part  they  also  agree  that  the  upper  half  is  affected 
oftener  than  the  lower  and  the  outer  half  oftener  than  the  inner.  The 
lower  inner  quadrant  escapes  oftener  than  any  other  part. 

So  far  as  the  operative  treatment  of  carcinoma  of  the  breast  is 
concerned,  only  since  1867  have  we  been  able  to  speak  of  success. 
It  was  then  that  Moore  taught  that  the  entire  gland  must  be  consid- 
ered diseased,  and  not  only  the  tumor  but  the  entire  gland  as  well, 
should  be  removed.  Along  with  increased  knowledge  of  the  ways 
in  which  cancer  of  the  breast  spreads,  which  was  especially  fur- 
thered by  Volkman,  Kuster,  Gerota,  Stiles,  Grossmann  and  Rotter, 
the  operative  treatment  has  become  more  and  more  radical.  During 
this  time,  Kuster  in  1883,  advocated  the  removal  of  the  regional 
lympth  glands  in  operations  on  the  cancerous  breast,  and  all  other 
cancers.  Rotter  showed  that  in  movable  tumors,  when  neither  the 
pectoralis  major  nor  its  fascia  were  affected,  the  lympth  glands 
under  the  pectoralis  major  contained  metastases.  He  demonstrated 
in  11  out  of  35  cases  that  the  lymphatics  of  the  breast  passed 
through  the  pectoralis  major  and  in  this  way  could  carry  cancerous 


330     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

cells  to  the  retromuscular  glands  at  an  early  date.  Grossmann  had 
succeeded  in  demonstrating  this  but  3  times  in  30  examinations.  Be- 
cause of  this  fact,  Rotter  advised  the  routine  removal  of  the  sternal 
portion  of  the  pectoralis  major  together  with  the  entire  pectoralis 
minor;  the  latter  interferes  with  exposure  of  the  axillary  space  and 
is  itself  often  the  seat  of  metastases.  Halstead  is  even  more  radical, 
in  that  he  removes  the  supraclavicular  glands  in  every  case  after  a 
temporary  resection  of  the  clavicle. 

{To  be  continued.) 


EXTRACTS  FROM  JOURNALS  331 


ExtrartB  fnim  ^nmt  ani  Jnr^tgn  iournala 


SURGICAL 


Nerve  Blocking  in  Treatment  of  Causalgia. 


Pitres  and  Marchand  report  that  Sicard's  method  of  injecting 
diluted  alcohol  into  the  trunk  nerve  has  put  an  end  to  the  distressing 
cases  of  intense  pain,  or  causalgia,  following  a  war  wound.  Before 
this  method  was  introduced,  they  had  numbers  of  wounded  suffering 
tortures  from  this  cause  which  they  were  unable  to  relieve  by  any 
measures.  The  pains  subsided  at  once  on  blocking  the  nerve  with 
alcohol,  injecting  60  per  cent  alcohol  into  the  nerve  above  the  lesion 
in  the  thirty  patients  given  this  treatment.  Three  cases  are  described 
in  detail  to  demonstrate  that  this  nerve  blocking  does  not  aggravate 
preexisting  motor  paralysis  or  bring  on  new.  On  the  contrary,  when 
the  pain  was  arrested  by  the  alcohol,  certain  other  disturbances  dis- 
appeared with  it,  especially  the  co-organic  paralysis,  the  nature  of 
which  is  still  a  mystery.  The  causalgia  in  the  first  case  had  per- 
sisted for  a  year,  not  modified  by  an  operation  to  free  the  nerve  em- 
bedded in  cicatrical  tissue.  The  second  patient  had  been  wounded 
in  the  thigh,  and  the  causalgia  accompanied  paresis  in  the  domain 
of  the  femoral  nerve.  The  femoral  nerve  was  opened  up  under  chlo- 
roform and  4  c.c.  of  60  per  cent  alcohol  injected.  The  pains  disap- 
peared at  once,  and  also  the  paresis  but  more  gradually.  Alcohol  at 
60  per  cent  interrupts  conduction  of  sensation  but  apparently  does 
not  modify  conduction  of  motor  impulses.  Before  the  nerve  block- 
ing there  was  partial  reaction  of  degeneration,  but  this  gradually 
became  total  notwithstanding  the  conservation  of  volitional  contrac- 
tility in  the  muscles  involved.  In  the  third  case  the  pains  were  in 
the  palm  although  the  wound  was  on  the  arm.  The  alcohol  was  in- 
jected in  the  wrist,  but  this  induced  merely  a  very  brief  and  fleetino- 
relief  of  the  pain.    This  experience  sustains  Sicard's  directions  that 

the  nerve  has  to  be  blocked  above  the  lesion  to  be  effectual. The 

Journal  of  the  Am.  Med.  Asso. 


332     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 
Acute  Appendicitis. 


There  were  thirty-four  deaths,  or  a  mortality  of  6.8  per  cent, 
among  the  500  cases  analyzed  by  the  authors.  Twice  as  many  died 
who  were  operated  on  the  third  day  after  the  onset  of  symptoms  as 
on  any  other  day  of  the  illness.  The  mortality  of  those  under  10 
years  and  over  50  is  23  per  cent  as  opposed  to  a  mortality  of  4.7  per 
cent  for  those  between.  Complications  were  found  in  151  persons, 
or  30  per  cent.  There  were  107  cases  of  appendicular  abscess,  or 
21  per  cent.  The  mortality  was  5.7  per  cent.  There  were  forty-five 
instances  of  diffuse  peritonitis,  or  9  per  cent.  Twenty-one,  or  47  per 
cent,  of  these  patients  died.  Fecal  fistula  occurred  twenty-four  times, 
an  incidence  of  2.5  per  cent.  There  were  four  fatalities  in  the  series, 
or  33  per  cent.  Secondary  peritoneal  abscess  occurred  in  eleven  in- 
stances, being  present  in  one  patient  at  operation  and  ten  times  as  a 
sequel.  Three  of  these  were  subphrenic  abscesses.  Of  the  eleven 
cases,  four  patients  died,  a  mortality  of  36  per  cent.  Only  two  cases 
of  ileus  were  found:  One  was  due  to  adhesions;  the  other  was  a  par- 
alytic ileus. 

A  history  of  previous  attacks  was  obtained  in  one-fourth  of  the 
cases.  Vomiting  was  mentioned  in  the  histories  of  four-fifths  of  the 
cases.  Five  per  cent  more  had  nausea  without  vomiting.  Constipa- 
tion was  five  times  as  frequent  as  diarrhea.  A  blood  count  was  re- 
corded in  377  of  the  cases.  Neither  a  normal  blood  count  nor  a  very 
high  one  rules  out  appendicitis,  although  such  counts  are  compara- 
tively rare.  The  mortality  was  higher  among  the  two  extremes  and 
most  favorable  with  a  moderate  leukocytosis.  The  relation  of  the 
numerical  count  to  the  differential  count  did  not  appear  to  have  any 
prognostic  significance.  Of  117  perforated  cases  seventeen  died,  a 
mortality  of  15  per  cent.  Of  138  cases  with  gangrene  and  no  per- 
foration nine  died,  a  mortality  of  6.5  per  cent.  Of  180  suppurative 
cases  without  either  perforation  or  gangrene  four  patients  died,  a 
mortality  of  2  per  cent.  Thirty  per  cent  of  perforated,  16  per  cent 
of  gangrenous  and  10  per  cent  of  suppurative  cases  developed  ab- 
scesses. Twenty-four  per  cent  of  perforated,  8  per  cent  of  gangren- 
ous, and  1  per  cent  of  suppurative  developed  diffuse  peritonitis.   The 


EXTRACTS  FROM  JOURNALS  333 

incidence  of  all  complications  in  perforative  cases  is  61  per  cent,  in 
gangrenous  38  per  cent,  and  in  suppurative  22  per  cent.  It  appears 
from  this  that  the  danger  of  a  diffuse  peritonitis  is  greater  when  there 
is  a  perforation  than  when  the  inflammation  spreads  through  the  ap- 
pendicular wall,  for  in  the  latter  case  there  is  a  better  chance  of  the 
peritoneum  localizing  the  disease.  There  were  twenty  cases,  or  four 
per  cent,  in  which  it  was  not  possible  to  remove  the  appendix.  All 
but  two  of  these  were  in  abscess  cases.  Three  of  the  twenty  patients 
died,  a  mortality  of  15  per  cent — Journal  of  the  Am.  Med.  Asso. 


Early  Diagnosis  and  Surgical  Treatment  of  Gall- 
bladder Disease, 


L.  C.  Kern  (Jour.  Iowa  State  Med,  Soc),  epitomizes  his  views  as 
follows.  First,  Gall-bladder  disease  is  not  diagnosed  sufficiently 
early.  In  many  cases  of  cholecystitis  and  gall-stones,  the  patients 
are  treated  for  some  other  malady  based  upon  a  faulty  diagnosis. 
If  surgical  treatment  is  given,  the  operation  has  been  so  long  de- 
layed that  the  best  results  are  not  obtained,  and  while  our  percentage 
of  course  is  great,  the  complications  arising  from  delay  make  the 
end  results,  in  many  cases,  undesirable.  Second,  infection  of  the 
gall-bladder,  with  or  without  gall-stones,  is  always  a  surgical  dis- 
ease. Third,  many  of  the  metabolic  faults  and  secondary  infections, 
such  as  rheumatism  may  have  their  origin  in  the  gall-bladder.  Fourth 
cancer  of  the  gall-bladder  is  clearly  proven  to  be  associated  with  a 
chronic  irritation  of  the  gall-bladder  due  to  gallstones,  with  a  prob- 
able infective  agent  as  a  further  cause.  Fifth,  by  an  early  diagnosis 
and  proper  surgical  treatment  we  will  prevent  many  of  our  patients 
from  having  secondary  infections  from  improper  medical  treatment 
or  delayed  surgery.  That  we  will  prevent  the  most  potent  exciting 
cause  known  at  this  time  as  a  causative  agent  in  cancer  of  the  gall- 
bladder,— Medical  Progress. 


334  EXTRACTS  FROM  JOURNALS 

MEDICAL 


Indicanemia,  Symptom  of  Renal  Insufficiency. 


Tcherkoflf  refers  to  the  recent  progress  of  our  knowledge  of  azo- 
temia. Retention  of  nonalbuminous  nitrogen  was  known  even  to 
some  of  Bright's  contemporaries  and  there  are  numerous  old  studies 
of  the  subject  which,  however,  led  to  conflicting  conclusions.  Strauss 
was  the  first  to  arrive  at  harmonious  results,  and  to  revive  the  flag- 
ging interest,  and  Widal  and  Javal  distinguished  between  chlorine 
retention  and  nitrogen  retention.  It  was  recognized  by  Weil  that  the 
latter  means  something  more  than  excess  of  blood  urea.  Two  other 
substances,  creatinine  and  indican,  began  to  receive  attention.  It 
was  shown  that  uremia  of  a  certain  clinical  type  was  not  dependent 
on  nitrogen  retention — eclamptic,  or  pseudouremia.  It  was  also 
learned  that  "considerable  degree  of  nitrogen  retention  could  occur 
without  the  development  of  uremia  and  that  in  such  cases  a  strong 
indicanemia  could  be  present.  Conversely  uremia  could  occur  with 
but  little  urea  retention,  and  in  such  cases  indican  could  be  absent 
from  the  blood.  The  technic  for  measuring  blood  indican  is  some- 
what complicated,  and  this  fact  had  led  the  author  to  devise  a  more 
simple  method.  He  punctures  a  vein  to  obtain  8  or  10  c.c.  of  blood 
serum,  adds  an  equal  quantity  of  20  per  cent  trichloracetic  acid  and 
filters.  The  10  c.c.  of  filtrate  he  adds  an  equal  amount  of  concen- 
trated HCl,  containing  5  grams  per  liter  of  perchloride  of  iron.  The 
mixture  is  then  shaken  and  3  c.c.  of  chloroform  added.  During  the 
next  15  minutes  the  mixture  is  shaken  several  times.  If  indican  is 
absent  no  coloration  appears.  If  present  a  pale  to  dark  blue  color  is 
manifest,  varying  with  the  amount  of  indican  present.  This  method 
is  also  of  value  for  the  recognition  of  iodine  in  the  blood,  the  pres- 
ence of  which  is  shown  by  a  rose  or  rose  violet  color.  The  two  reac- 
tions tend  to  cause  confusion,  and  no  test  for  indican  should  be  made 
on  patients  who  are  taking  iodides.  The  amount  of  indican  is  esti- 
mated by  control  color  solutions.  The  test  is  so  simple  that  no  prac- 
titioner can  aff"ord  to  omit  it.  If  indican  is  present  at  all  it  implies 
an  azotemia  of  about  1.5  per  cent,  and  always  means  renal  insuffi- 


EXTRACTS  FROM  JOURNALS  335 

ciency.  If  the  patient  have  chronic  nephritis  it  signifies  a  fatal  end- 
ing within  a  few  months — often  a  few  weeks.  In  certain  of  these 
cases  the  blood  urea  is  barely  increased.  Azotemia  is  by  no  means 
synonymous  with  uremia. — Medical  Record. 


Relation  of  Dental  Infection  to  Cancer. 


In  an  article  on  "Prevention  of  any  Treatment  of  Cancer  Based 
upon  X-ray  Findings  of  Dental  Infection.'  Sinclair  Tousey  (N.  Y. 
Med.  Jour,  asserts  that  his  own  observations  show  severe  dental  in- 
fection in  all  cancer  patients.  No  complete  study  of  the  microor- 
ganisms in  these  abscesses  has  yet  been  made ;  the  reports  on  the  cul- 
tures so  far  showing  the  presence  of  streptococcus  viridans  and  non- 
pathogenic organisms.  He  believes  that  researches  made  with  a  view 
of  identifying  the  different  organisms  may  discover  a  specific  cancer 
germ  or  a  specific  strain,  or  it  may  show  that  inveterate  infection 
with  any  of  the  organisms  will  eventually  produce  cancer  in  a  cer- 
tain percentage  of  cases.  While  it  is  not  to  be  supposed  that  every 
case  of  dental  infection  leads  to  cancer,  the  early  discovery  and 
eradication  of  all  dental  infections  will  doubtless  prevent  cancer  of 
the  stomach  and  gall-bladder,  and  possibly  many  cancers  of  other 
internal  and  external  organs.  The  existence  of  severe  dental  infec- 
tion in  his  cases  of  cancer  of  the  breast  is  not  to  be  lightly  regarded 
as  a  coincidence  when  the  same  sort  of  infection  has  been  proven  to 
be  causative  of  cancer  of  the  stomach.  X-ray  examination  of  the 
teeth  should  be  made  in  patients  with  cancer  so  as  to  discover  and 
eradicate  foci  of  infection,  and  the  sooner  this  is  done  the  better  the 
chance  of  success  with  operation  by  the  knife  or  electricity,  com- 
bined with  X-ray  and  radium.  An  autogenous  vaccine  prepared 
from  the  micro-organisms  in  dental  abscesses  will  doubtless  be  indi- 
cated in  a  greater  percentage  of  cancer  patients  than  among  the 
arthritic  cases,  where  the  eradication  of  the  dental  focus  usually 
overcomes  the  general  infection.  The  patient's  hopes  should  not  be 
unduly  raised,  because  even  if  the  autogenous  vaccine  proves  to  be  a 
specific,  the  nature  or  the  stage  of  the  disease  may  make  death 
inevitable — Medical  Progress. 


336     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 
OBSTETRICAL 


Twilight  Sleep. 


Burton  A.  Washburn,  M.D.,  (Medical  Summary),  says:  I  want  to 
call  your  attention  to  one  fact,  and  you  can  refer  to  any  neuralist  and 
he  will  tell  you  that  our  own  native  Americans  are  people  of  high 
nerve  tension  and  that  they  do  not  have  that  relaxing  or  resigned 
temperament  that  you  see  in  other  nationalities.  You  can  not  pick 
them  up  and  dope  them  on  narcotics  in  frequent  enough  doses  to 
give  them  complete  freedom  from  pain  without  showing  toxic  reac- 
tion in  a  great  many  cases. 

Now,  I  am  dealing  with  every-day  truths,  and  you  can  take  the 
records  in  any  of  the  hospitals  in  large  cities,  and  the  records  will 
show,  taking  the  nationality  as  the  foundation,  that  our  native  Amer- 
icans are  more  responsive  for  worse  or  better  than  any  other  race  of 
people.  I  make  this  statement  to  show  nerve  reaction,  and  why 
scopolamin-morphine  has  practically  gone  into  disuse  in  the  past 
few  years.  And  why  it  is  now  revived  is  best  known  to  many  who 
advocate  their  use  in  all  cases.  Conservatism  is  the  professional 
foundation,  and  the  man  who  carries  the  same  as  a  side  line  and  ap- 
peals to  the  sentimental  public  is  not  always  rewarded  for  such  a 
course.  Give  scopolamin-morphine  its  just  credit,  but  when  misfor- 
tune comes  to  a  case,  who  is  to  blame,  the  drugs  or  the  doctor?  If 
you  cause  the  doctor  to  take  up,  or  renew,  a  bad  line  of  practice 
which  is  already  being  done,  by  such  public  sentiment  to  have  dis- 
aster in  cases,  due  the  fine  reports  of  others,  who  have  you  benefited? 

I  want  to  say  that  I  have  seen  satisfactory  results  with  this  drug, 
but  I  have  also  seen  susceptible  cases  to  toxic  drug  reaction  show 
violent  delirium,  prostration  and  complete  relaxation  of  all  pains, 
and  instruments  were  necessary  to  complete  the  case,  which  other- 
wise would  have  been  a  normal  labor. 

It  is  claimed  that  the  use  of  scopolamin-morphine  lessons  the 
deathrate  of  childbirth;  it  renders  labor  painless:  it  lessons  forceps 
delivery  and  forceps  lacerations;  it  shortens  time  of  labor;  hemor- 
rhage is  not  apt  to  follow  its  use. 


EXTRACTS  FROM  JOURNALS  337 

Now,  the  facts  about  its  use  that  I  will  make  mention  are  condi- 
tions which  I  have  witnessed.  I  will  give  them  to  you  as  they  act- 
ually existed: 

Scopolamin  will  stop  labor,  I  have  seen  delirium  from  the  mut- 
tering of  senseless  expressions  to  such  violent  physical  resistance 
that  the  patient  had  to  be  strapped  in  bed.  It  will  not  stop  sensi- 
bility to  pain  without  producing  some  complication  in  most  cases. 
It  causes  muscles  to  loose  their  tenacity  and  tear  like  paper.  It 
places  the  patient  in  grave  danger  after  labor  from  hemorrhage,  be- 
cause it  inhibits  the  contractile  power  of  the  entire  uterine  muscle. 

— Medical  Progress. 

Indications  for  Interference  in  Pre-eclamptic  Toxemia. 


Dr.  William  G.  Dice,  Toledo,  Ohio:  The  character  and  quantity 
of  the  waste  products  from  a  study  of  urine  are  not  definite  indexes 
of  severity  of  the  toxemia.  The  systolic  blood  pressure  taken 
throughout  pregnancy  is  ordinarily  a  better  index.  A  steady  increas- 
ing rise  from  the  average  normal,  110  to  120,  up  to  150,  is  signifi- 
cant, and  there  is  a  sudden  increase  in  the  evidence  of  toxemia  when 
blood  pressure  reaches  that  point.  Elevated  blood  pressure  often 
precedes  albuminaria,  and  the  two  are  not  necessarily  proportional. 
When  the  blood  pressure  reaches  170,  if  other  signs  of  toxemia  are 
also  present,  time  for  expectant  treatment  is  near  an  end.  Toxins  in 
the  blood  give  rise  to  retinitis,  the  first  symptom  objectively  being 
edema,  later  infiltration,  degeneration  and  hemorrhages  or  perhaps 
detachment  of  the  retina;  both  the  latter  indicate  grave  toxemia.  In 
the  early  stage  of  retinitis,  the  vision  may  not  be  affected,  but  the 
ophthalmoscope  shows  a  haziness  of  the  fundus,  an  inability  to  make 
out  the  fine  details,  which  is  the  first  sign  of  cloudy  swelling.  The 
interference  with  vision  depends  on  the  location  of  the  lesion, 
whether  in  the  macula  or  only  in  the  areas  surrounding  it.  The 
condition  clears  up  entirely  if  it  does  not  go  beyond  the  stage  of 
cloudy  swelling.  In  primiparas  this  haziness  of  the  retina  is  easily 
detected  if  the  pupil  is  widely  dilated,  and  this  haziness  is  the  first 
indication  of  retinitis;  but  if  there  has  been  previous  eye  trouble,  it 
probably  can  not  be  made  out  so  early.     Conservation  of  vision  as 


338     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

well  as  life  demands  prompt  induction  of  labor, — The  Journal  of  the 
American  Medical  Association. 


The  Etiology  of  Mongolian  Imbecility. 


Why  the  Mongolian?  This  is  a  question  which  has  puzzled  scien- 
tists for  years.  Dr.  Herman  discusses  the  subject  rather  fully  from 
theories  already  put  forward. 

Worry,  emotional  shock,  and  diseases  of  the  mother  during  preg- 
nancy have  always  been  popular  theories  which  help,  especially  the 
laity,  to  explain  the  occurrence  of  their  unfortunate  issue.  No  scien- 
tific data,  however,  is  obtainable  to  substantiate  such  theories. 

Immaturity  or  exhaustion  of  the  generative  organs,  especially  of 
the  mother,  is  another  theory  rather  popular  with  the  profession.  A 
certain  percentage  of  the  mothers  of  mongols  are  very  young  or  very 
old.  In  about  one-third,  the  mother  is  over  40  years  old.  However, 
there  remain  the  two-thirds  in  which  the  mothers  are  between  20  and 
40.  Large  numbers  of  perfectly  normal  children  are  born  to  moth- 
ers over  40,  and  there  is  no  evidence  to  show  that  such  children  are 
usually  weaker  physically  and  mentally  than  those  of  preceding 
pregnancies. 

There  may  have  been  pressure  on  the  basal  ganglia,  as  shown  by 
the  short  antero-posterior  diameter  of  the  skull,  the  flat  occiput,  and 
the  diminished  weight  of  the  cerebellum,  pons,  and  medulla.  The 
primary  factor  is  not  the  deformity  of  the  skull,  but  the  incomplete 
development  of  the  brain. 

Congenital  syphilis  is  considered  a  strong  etiological  factor  with 
many  observers,  but  the  consensus  of  opinion  is  that  syphilis  is  not 
responsible  for  the  great  majority  of  cases. 

The  most  suggestive  evidence  concerning  the  cause  of  mongolian 
imbecility  is  a  unit  character  and  recessive,  following  the  Mendelian 
principles.  A  number  of  charts  are  shown  by  Dr.  Herman  to  illus- 
trate and  substantiate  this  theory.  He  concludes  that  there  is  no 
positive  proof  that  worry,  emotional  shock,  illness  during  preg- 
nancy, or  congenital  lues  are  important  factors  in  the  causation  of 
mongolian  imbecility.  The  evidence  that  the  condition  is  a  unit 
character  and  recessive,  although  not  conclusive,  is  certainly  sug- 
gestive.— The  Virginia  Medical  Semi-monthly. 


EDITORIALS  339 


lEbttnrtal 


PUBLISHER'S  NOTICE— The  Journal  is  published  in  monthly  numbers  of 
48  pages  at  ?1.00  a  year,  to  be  always  paid  in  advance. 

All  bills  for  advertisements  to  be  paid  quarterly,  after  the  first  insertion  of 
the  quarter. 

Business  communications,  remittances  by  mail,  either  by  money  order, 
draft,  or  registered  letter,  should  be  addressed  to  the  Business  manager,  C. 
S.  Briggs,  M.D.,  corner  Summer  and  Union  Streets,   Nashville,   Tenn. 

All  communications  for  the  Journal,  books  for  review,  exchanges,  etc., 
should  be  addressed  to  the  -Editor. 


Compulsory  Food  Conservation. 


Among  our  allies,  food  tickets  and  allowances  have  been  in  effect 
almost  since  the  beginning  of  the  war.  Those  behind  the  lines,  as 
well  as  those  in  the  trenches,  for  more  than  three  years,  have  had 
to  deny  themselves  all  the  luxuries  and  many  of  the  necessities  of 
an  equalized  diet.  We  now  realize  that  our  allies  were  fighting  for 
our  safety,  as  well  as  their  own  from  the  first  day  of  the  war.  With- 
out our  help  the  German  arms  may  have  been  crowned  with  victory, 
and  even  with  our  help,  no  one  today  knows  whether  the  final  terms 
at  the  close  of  the  war  will  be  such  as  to  insure  a  lasting  peace.  It, 
therefore,  behooves  us  to  do  everything  possible  to  help  our  allies, 
and  to  help  our  soldiers  at  the  front  and  their  dependents  left  behind. 

Red  Cross  donations,  donations  to  the  Army  Y.  M.  C.  A.,  to  the 
starving  Belgians,  to  the  French  Heroes  Fund,  purchase  of  Liberty 
Bonds  and  all  other  expenditures  of  money  to  help  our  allies  and 
our  own  government,  are  truly  patriotic,  but  no  one  of  these  finan- 
cial expressions  of  patriotism  means  so  much  as  would  a  general 
compulsory  conservation  of  food,  such  as  can  only  be  obtained  by 
food  allowances.  Boys  who  are  to  protect  our  shores  from  the  in- 
vasion of  a  foreign  foe  are  chosen  from  all  walks  of  life;  many  of 
them  have  been  accustomed  to  the  best  money  could  buy;  on  the 
other  hand  many  are  leaving  dependents  behind,  who  had  difficulty 


340     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

in  obtaining  food  enough  even  with  the  head  of  the  family  at  home 
and  at  work.  These  boys  are  to  offer  their  lives  and  to  suffer  the 
hardships  of  modern  war  that  we  may  live  in  comfort.  Some  of 
them  volunteered  for  the  adventure,  some  from  a  sense  of  duty,  and 
some  of  necessity.  Regardless  of  why  they  are  in  the  army,  it  is  no 
more  than  we  owe  these  boys  and  their  dependents  to  deny  ourselves 
some  of  the  luxuries  and  necessities  they  can  not  obtain. 

Food  conservation  speeches  and  demonstrations  reach  a  small 
number  of  people  and  are  heeded  by  an  even  smaller  number;  they 
can  never  affect  the  great  mass  of  American  people.  Just  as  it  took 
a  draft  law  to  raise  our  national  army,  so  will  it  require  a  food  law 
to  conserve  our  food  and  keep  down  the  prices.  We  owe  it  to  our 
allies  and  to  our  own  army  to  enact  and  enforce  such  a  law.  It 
would  be  our  greatest  expression  of  patriotism;  it  would  cheer  our 
boys  at  the  front  to  feel  that  those  who  remain  at  home  are  willing 
to  share  some  of  the  hardships  of  this  war;  it  would  bring  a  full  re- 
alization of  our  part  in  the  war  to  the  hearts  of  the  American  peo- 
ple; it  would  force  the  wealthy  class  into  a  better  realization  of  the 
suffering  of  the  poor,  who  at  the  present  time  can  hardly  afford  to 
buy  the  food  necessities;  by  conserving  the  food  supply  it  would 
tend  to  lower  prices  as  well  as  allow  more  food  for  our  allies,  and 
in  this  way  give  the  poorer  of  the  dependents  left  at  home,  a  chance 
to  live  comfortably  until  the  provided  returns;  it  would  be  one  more 
blow  to  the  vaunted  Prussian  Militarism,  and  finally  it  would  show 
that  the  United  States  is  heart  and  soul  and  really  united  in  this  war 
for  Liberty  and  Democracy. 

W.  T.  B. 


Suicide  More  Prevalent  Among  Men  than  Women. 


The  figures  show  that  the  suicide  is  more  than  twice  as  frequent 
as  a  cause  of  death  among  males  than  among  females.  This  is  true 
at  all  periods  of  life  except  at  the  ages  of  15  to  19.  It  is  remarkable 
that  the  change  from  youth  to  adult  life  should  disturb  the  mental 
life  of  females  so  much  more  than  that  of  males.  The  same  condi- 
tions are  found  to  prevail  among  the  white  and  the  colored  races. 
After  early  adolescence,  the  white  female  suicide  rate  remains  prac- 


EDITORIALS  341 

tically  stationary,  never  varying  very  much  from  about  11  per  100,- 
000.  On  the  other  hand,  the  white  male  suicide  rate  increases  with 
each  age  period.  The  rate  is  highest  at  the  ages  65  to  74,  when  it  is 
over  80  per  100,000.  Suicide  is  then  a  very  common  cause  of  death, 
nearly  five  times  as  prevalent  as  the  age  period  20  to  24. 


Young  Physicians,  Your  Opportunity. 


Never  again  in  the  history  of  medicine  in  this  country  will  such 
an  opportunity  be  afforded  you  to  serve  your  country  as  well  as  the 
best  interest  of  yourself. 

The  experience  which"  you  will  gain  by  being  commissioned  in  the 
Medical  Reserve  Corps  and  seeing  active  service,  will  be  worth  more 
to  you  in  a  professional  way  than  you  could  acquire  in  years  of 
practice  in  civil  life. 

The  pay  granted  to  officers  in  the  Medical  Reserve  Corps  is  suffi- 
cient not  only  to  cover  all  needs,  but  enable  you  to  lay  aside  a  com- 
fortable balance,  and  while  the  older  men  in  the  profession  have 
come  forward,  it  is  to  the  younger  men  that  the  greatest  benefits 
accrue. 

The  experience  will  prove  broadening  both  professionally  and 
mentally.  With  this  experience  and  the  thought  that  you  have  served 
your  country  in  time  of  need,  you  will  return  to  civil  life  and  re- 
ceive the  further  benefits  from  your  patients,  friend  and  acquaint- 
ances, always  accorded  to  one  who  has  been  so  prominently  indi- 
vidualized as  this  opportunity  will  afford. 


In  October,  the  senior  editor  of  this  Journal,  Dr.  C.  S.  Briggs,  was 
appointed  Chief  Surgeon  of  the  Tennessee  Central  Railroad  and 
Briggs'  Infirmary  was  designated  as  hospital  for  patients  of  that 
system. 


To  Officers  of  the  Medical  Reserve  Corps  U.  S.  Army 
Inactive  List. 


Word  received  from  the  Surgeon  General  of  the  U.  S.  Army  con- 
veys the  information  to  officers  of  the  Medical  Reserve  Corps  of  the 


342      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

United  States  Army,  inactive  list,  that  assignment  to  active  duty  may 
be  delayed,  and  that  they  are  advised  to  continue  their  civilian  ac- 
tivities, pending  receipt  of  orders.  They  will  be  given  at  least  fifteen 
days'  notice  when  services  are  required. 


The  delayed  appearance  of  the  November  number  of  the  Journal 
is  due  to  a  fracture  of  the  anatomical  neck  of  the  humerus  sustained 
by  the  editor.  Dr.  C.  S.  Briggs,  in  a  fall  caused  by  missing  a  step  on 
the  stairway  of  his  office,  November  5th.  Repair  now  is  nearly  com- 
plete and  he  will  soon  be  ready  to  resume  all  his  work. 


We  take  great  pleasure  in  presenting  the  translation  of  the  most 
excellent  paper  on  Cancer  in  this  number  of  the  Journal  and  offer 
an  apology  for  having  to  make  two  installments,  but  feel  sure  that 
the  value  of  the  article  will  make  ample  atonement  for  that  incon- 
venience to  our  readers. 


Resolution  adopted  unanimously  by  the  Clinical  Congress  of  Sur- 
geons of  North  America  at  Chicago,  October  25,  1917: 

Whereas,  The  experiences  of  the  nation  convince  us  of  the  ne- 
cessity for  Universal  Military  Training,  to  furnish  qualified  men  for 
defense,  to  strengthen  manhood  and  mental  poise,  and  to  make  for 
a  more  efficient  citizenship;  and 

Whereas,  We  believe  it  will  demonstrate  youth  and  furnish  dis- 
cipline, while  developing  physical  force  and  endurance,  and  will 
produce  better  fathers  and  workers  for  the  ranks  of  peace;  therefore 
be  it 

Resolved,  That  the  Clinical  Congress  of  Surgeons  at  its  eighth 
annual  session  urge  upon  Congress  at  its  eight  annual  session 
the  passage  of  a  measure  along  the  general  lines  of  the  Chamber- 
lain Bill  for  Universal  Military  Training,  and  that  the  cantonments 
now  used  by  the  National  Army  be  utilized,  if  possible,  for  such 
work. 


We  hope  our  subscribers  will  remember  that  we  are  nearly  at  the 
close  of  the  year  and  that  they  will  not  forget  to  send  in  what  they 


EDITORIALS  343 

owe  for  subscription  and  order  the  subscription  continued  for  an- 
other year.  At  least  notify  us  to  continue  sending  the  Journal  or  not, 
as  that  will  save  us  a  good  deal  of  trouble. 


Do  You  Know  That 


Light  promotes  cleanliness? 

A  clean  mouth  is  essential  to  good  health? 

Physical  training  in  childhood  is  the  foundation  of  adult  health? 

The  U.  S.  Public  Health  Service  issues  publications  on  hygiene 
and  sanitation  for  free  distribution? 

Isolation  is  the  most  efficient  means  of  controlling  leprosy? 

Headache  is  Nature's  warning  that  the  human  machine  is  running 
badly? 

Bullets  may  kill  thousand — flies  tens  of  thousands? 

Obesity  menaces  longevity. 


The  following  resolutions  were  adopted  unanimously  at  a  meet- 
ing of  Committees  from  all  states  (except  Maine  and  Delaware), 
held  in  the  Congress  Hotel,  Chicago,    October  23,  1917: 

Whereas,  The  experience  through  which  the  United  States  is  now 
passing  should  convince  every  thoughtful  person  of  the  necessity  for 
universal  training  of  young  men,  not  only  for  the  national  defense 
in  case  of  need,  but  also  to  develop  the  nation's  greatest  asset — its 
young  manhood — in  physical  strength,  in  mental  alertness,  and  in 
respect  for  the  obligations  of  citizenship  essential  in  a  democracy; 
therefore,  be  it 

Resolved  by  the  State  Committees  of  the  Medical  Section  of  the 
Council  of  National  Defense  that  they  strongly  urge  the  adoption  by 
our  government  at  this  time  of  a  comprehensive  plan  of  intensive 
universal  military  training  of  young  men  for  a  period  of  at  least 
six  months,  upon  arriving  at  the  age  of  nineteen  years  and  that  this 
body  also  support  the  movement  to  secure  the  introduction  into  pub- 
lic schools  of  adequate  physical  training  and  instruction; 

Resolved,  That  the  members  of  each  State  Committee 
immediately  take  active  steps  to  insure  public  support  for  the  sub- 


344      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

ject  of  these  resolutions  ihrough  the  newspapers,  through  public 
meetings  and  through  the  appointment  of  committees  in  each  county; 
also  that  copies  of  these  resolutions  be  forwarded  to  the  Senators 
and  Members  of  Congress  in  their  respective  states,  with  a  personal 
request  that  favorable  action  be  taken  at  the  coming  session  of  Con- 
gress upon  a  measure  following  the  principle  of  the  Chamberlain 
Bill  and  to  become  operative  as  soon  as  the  army  cantonments  are 
no  longer  required  for  the  training  of  the  forces  in  the  present  war; 
Resolved,  that  each  State  Committee  from  time  to  time  report  to 
the  Medical  Section  of  the  Council  of  National  Defense  as  to  action 
and  progress  secured  in  their  several  states. 


Warning  Against  Medicine  Fraud. 


Washington,  D,  C. — Imposters  posing  as  Federal  employes  are 
trying  to  sell  rheumatism  and  other  "cures"  which  they  represent  to 
the  gullible  as  being  made  by  the  United  States  Government,  is  a 
warning  issued  today  by  the  Bureau  of  Chemistry,  United  States 
Department  of  Agriculture.  Letters  received  from  residents  of  Min- 
nesota and  South  Dakota  tell  of  such  misrepresentations  by  agents 
of  the  United  States  Medical  Dispensary"  or  "Dr.  Henry  Post," 
Washington,  D.  C.  The  packages  and  labels  guaranteed  for  $20 
"cures"  for  various  ailments  but  failed  to  give  any  address  of  those 
who  are  to  refund.  Federal  inspectors  have  been  unable  to  locate 
any  such  concern  or  doctor  in  Washington  or  elsewhere. 

The  label  contains  a  serial  number  and  states  that  the  "product" 
is  "guaranteed  by  Dr.  Post  under  the  national  pure  food  and  drugs 
act  of  June  30,  1906."  The  number  given  is  that  assigned  to  a  con- 
cern which  has  never  made  such  a  product  and  has  no  connection 
with  Dr.  Post  or  a  Dr.  George  Lawrence  of  South  Dakota  who,  ac- 
cording to  a  correspondent,  represented  himself  as  both  Dr.  Post's 
agent  and  an  employe  of  the  United  States  Government. 

The  department's  inspectors  can  not  find  that  the  product  is  being 
shipped  in  interstate  commerce,  which  would  bring  it  under  the 
Food  and  Drugs  Act  and  are  of  the  opinion  that  the  agents  carry  it 
personally  to  escape  detection  by  the  Federal  authorities.     The  de- 


EDITORIALS  345 

partment  therefore  has  brought  the  matter  to  the  attention  of  va- 
rious State  and  city  food  and  drug  ofiScials  with  the  view  of  securing 
their  co-operation  in  detecting  and  preventing  such  fraudulent  prac- 
tices. 


Kindly  note  the  following  change  of  address:  The  Southern  Cali- 
fornia Practitioner  from  3438  Siskiyou  Street  to  133  South  Hobart 
Blvd.,  Los  Angeles,  Cal. 


Memorandum. 


To  Editors  of  Medical  Journals  in  the  United  States: 

It  is  the  utmost  importance  that  the  medical  profession  through- 
out the  country  be  kept  informed  in  regard  to  the  activities  of  the 
Surgeon  General's  office,  the  Medical  Section  of  the  National  Council 
of  Defense  in  Washington,  and  the  work  the  State  Committees. 

There  should  be  no  difficulty  in  getting  this  information  by  writing 
directly  for  it. 

The  enclosed  reprint  gives  specific  and  authentic  information  up 
to  September,  1917. 

Since  then  the  situation  of  the  Medical  Reserve  Corps  in  regard 
to  numbers  has  become  less  acute.  About  14,000  are  commissioned 
and  7,000  are  in  the  process  of  being  commissioned. 

Twenty-one  thousand  medical  officers  are  about  sufficient  for  an 
army  of  2,000,000  men. 

The  indications  are  that  we  will  need  a  much  larger  army,  and 
the  medical  profession  of  this  country  will  be  tested  to  its  utmost 
capacity. 

At  a  recent  meeting  in  Chicago  of  the  State  Committees  of  the 
National  Council  of  Defense  it  was  decided  to  petition  Congress  to 
create  a  Reserve  Redical  Officers  Reserve  Corps.  When  this  is  created 
every  qualified  physician  at  any  age  will  be  given  the  opportunity 
and  honor  to  volunteer  his  services  and  be  enrolled.  After  this  every 
physician  will  be  in  a  position  either  to  wear  the  insignia  of  honor 


346     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

of  the  Reserve  Medical  Officers  Reserve  Corps  or  the  uniform  of 
active  service  in  the  Medical  Officers  Reserve  Corps. 

From  the  new  Reserve  Medical  Officers  Reserve  Corps  the  Surgeon 
General  will  be  able  to  select  medical  officers  as  they  are  required 
for  service  in  France  or  at  home. 

The  present  great  problems  are:  The  training  of  physicians  in 
civil  practice  for  military  duty. 

The  protection  of  the  army  in  training  in  this  country  from  ven- 
ereal infection. 

The  future  great  problems  when  our  wounded  begin  to  return  to 
this  country  will  be  the  reconstruction  and  re-education  of  the  crip- 
pled soldiers. 

The  great  and  only  necessity  of  the  present  is  the  successful  car- 
rying on  of  this  war. 

The  medical  journals  of  this  country  should  do  all  in  their  power 
to  keep  the  profession  properly  informed  and  to  stimulate  them  for 
this  great  endeavor. 

Joseph  Colt  Bloodgood, 
Chairman  of  Committee  on  Preparedness  of  the  Southern  Medical 

Association. 


The  Secretary  of  the  Treasury,  Washington. 


To  the  Officers  and  Enlisted  Men  and  Women  of  the  Army  and  Navy 

of  the  United  States  and  Their  Relatives: 

The  Secretary  of  the  Treasury,  through  the  Bureau  of  War  Risk 
Insurance,  has  been  charged  with  the  administration  of  the  War  In- 
surance enacted  by  the  Congress  as  a  measure  of  justice  to  the  men 
and  women  who  have  been  called  to  give  their  lives,  if  need  be,  in 
the  service  of  their  country. 

I  wish  to  acquaint  you  with  the  benefits  and  privileges  which  your 
Government  has  placed  at  your  disposal.  It  is  essential  that  you  and 
your  families  at  home  should  know  of  your  and  their  rights  under 
this  law  in  order  that  full  advantage  may  be  taken  of  them. 

To  care  for  the  wife  and  children  of  the  enlisted  man  during  his 
service,  the  War  Insurance  Law  compels  him  to  contribute  up  to 


EDITORIALS  347 

one-half  of  his  pay  for  their  support.  The  Government,  on  applica- 
tion, will  generously  add  to  this  an  allowance  of  from  $5  to  $50  a 
month,  according  to  the  size  of  the  family.  Moreover,  if  the  enlisted 
man  will  make  some  further  provision  himself  for  a  dependent 
parent,  brother,  sister,  or  grandchild,  they  may  be  included  in  the 
Government  allowance. 

If  (  as  the  result  of  injuries  incurred  or  disease  contracted  in  the 
line  of  duty,  an  officer  or  enlisted  man  or  an  Army  nurse  should  be 
disabled,  provision  is  made  for  compensation  of  from  $30  to  $100 
a  month  to  him,  and,  should  he  die,  compensation  of  from  $20  to 
$75  a  month  will  be  paid  to  his  wife,  his  child,  or  his  widowed 
mother. 

In  order,  however,  fully  to  protect  each  person  and  family,  Con- 
gress has  made  it  possible  for  every  soldier,  sailor  and  nurse  to  ob- 
tain life  and  total-disability  insurance.  This  insurance  applies  to 
injuries  received  while  he  or  she  is  in  the  service  or  after  he  or  she 
shall  have  left  it. 

Exposure  to  the  extra  dangers  of  war  makes  the  cost  of  life  insur- 
ance in  private  life  insurance  companies  prohibitive.  It  was,  there- 
fore, plain  duty  and  obligation  for  the  Government  to  assume  the 
risk  of  insuring  hundreds  of  thousands  of  our  soldiers  and  sailors 
who  are  making  the  supreme  sacrifice.  Under  this  law,  every  soldier 
and  sailor  and  nurse,  commissioned  and  enlisted,  and  of  any  age,  has 
the  right,  between  now  and  February  12,  1918,  to  take  out  life  and 
total-disability  insurance  up  to  $10,000  at  very  low  cost,  with  the 
Government  without  medical  examination.  This  right  is  purely  op- 
tional. The  soldiers  and  sailors  are  not  compelled  to  take  this  insur- 
ance, but  if  they  desire  to  exercise  the  right,  they  must  do  so  before 
the  12th  of  February,  1918,  The  cost  ranges  from  65  cents  monthly, 
at  the  age  of  21,  to  $1.20  monthly,  at  the  age  of  51,  for  each  $1,000 
of  insurance.  This  is  a  small  charge  on  a  man's  pay — small  in  pro- 
portion to  the  benefits  it  may  bring.  The  premiums  will  be  deducted 
from  his  pay,  if  he  desires,  thus  eliminating  trouble  on  his  part. 

To  provide  adequate  protection  until  February  12,  1918,  during 
the  period  when  the  soldiers  and  sailors  are  learning  the  details  of 
this  law,    the  Government  automatically    insures    each    man    and 


348      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

woman,  commissioned  or  enlisted  in  the  military  service  of  the 
United  States.  It  pays  the  man  $25  a  month  during  total  permanent 
disability;  if  he  dies  within  20  years,  it  pays  the  rest  of  240  monthly 
installments  of  $25  each  to  his  wife,  child,  or  widowed  mother. 

I  desire  to  call  the  provisions  of  this  just  and  generous  law  to  the 
attention  of  our  officers  and  enlisted  men  and  women  so  that  they 
may  not  be  deprived  of  their  rights  through  lack  of  knowledge.  Full 
information  may  be  obtained  from  the  Bureau  of  War  Risk  Insur- 
ance of  the  Treasury  Department,  Washington,  D.  C.  I  earnestly 
urge  that  the  officers  of  the  Army  and  Navy  give  to  the  men  under 
their  command  all  possible  aid  in  helping  them  to  understand  fully 
the  benefits  that  this  insurance  may  bring  to  their  families  and  the 
small  cost  at  which  it  may  be  obtained.       , 

This  is  the  greatest  measure  of  protection  ever  offered  to  its  fight- 
ing forces  by  any  nation  in  the  history  of  the  world.  It  is  not  char- 
ity; it  is  simply  justice  to  the  enlisted  men  and  women  and  to  their 
loved  ones  at  home,  and  each  and  every  one  should  promptly  take  the 
benefits  of  this  great  law. 

W.  G.  McAdoo, 
Secretary  of  the  Treasury. 


HoxME  Canned  Food  Safe. 


No  Need  to  Fear  Botulism  in  Properly  Prepared  Products. 


Washington,  D.  C. — The  United  States  Department  of  Agriculture 
today  issued  the  following  statement  prepared  by  the  bacteriologists 
of  its  Bureau  of  Chemistry  and  the  States  Relations  Service: 

"There  is  no  danger  that  the  type  of  food  poisoning  known  as 
'Botulism'  will  result  from  eating  fruits  or  vegetables  which  have 
been  canned  by  any  of  the  methods  recommended  by  the  United 
States  Department  of  Agricultude,  provided  such  directions  have 
been  followed  carefully.  It  is  possible  that  in  a  number  of  instances 
the  directions  were  not  strictly  followed  and  that  spoilage  has  oc- 
curred.   Of  course,  extreme  care  should  be  taken  to  ascertain  before 


EDITORIALS  349 

eating  canned  goods  of  any  kind  whether  they  are  in  good  condition, 
and  if  they  have  spoiled  they  should  not  be  consumed. 

"In  case  of  any  doubt  as  to  whether  the  contents  of  a  particular 
can  have  spoiled,  the  safest  plan  is  to  throw  it  away,  although  all 
danger  of  Botulism  may  be  avoided  by  boiling  the  contents  of  the 
can  for  a  few  minutes,  since  the  Bacillus  botulinus  and  the  toxin  or 
poison  which  it  produces  are  killed  by  such  treatment.  No  canned 
food  of  any  kind  which  shows  any  signs  of  spoilage  should  ever  be 
eaten.  In  the  cold  pack  method  of  canning  given  out  by  the  Depart- 
ment of  Agriculture,  only  fresh  vegetables  are  recommended  for 
canning,  and  sterilization  is  accomplished  by  the  following  pro- 
cesses: cleansing,  blanching,  cold  dipping,  packing  in  clean,  hot 
jars,  adding  boiling  water,  sealing  immediately,  and  then  sterilizing 
the  sealed  ars  at  a  minimum  temperature  of  212  degrees  Fahrenheit 
for  one  to  four  hours,  according  to  the  character  of  the  material. 
Since  the  spores  of  B.  botulinus  are  killed  by  heating  for  one  hour 
at  175  degrees  Fahrenheit  (according  to  Jordan's  'Bacteriology'  and 
other  recognized  textbooks)  there  is  no  reason  to  believe  that  the 
botulinus  organism  will  survive  such  treatment." 


Treasury  Department,  Washington. 


November  10,  1917. 
To  the  Nashville  Journal  of  Medicine  and  Surgery: 

On  behalf  of  the  Woman's  Liberty  Loan  Committee  I  want  to  ex- 
tend to  you  our  heartfelt  thanks  and  appreciation  for  the  splendid 
co-operation  you  gave  us  in  obtaining  nation-wide  publicity  during 
the  Liberty  Loan  Campaign  just  closed. 

Yours  very  truly, 

Mrs.  Wm.  G.  McAdoo, 
Chairman  Woman  s  Liberty  Loan  Committee. 


350     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


Sftofofi  nnh  Sonk  Nuttr^fi 


Impotence  and  Sterility  with  Aberrations  of  the  Sexual  Function  and  Sex- 
Gland  Implantation— By  Frank  Lydston,  M.D.,  D.C.L.  Price  $4.  Sold  by 
subscription  Only.  Sent  postage  prepaid  on  receipt  of  Subscription  Price. 
The  Riverton  Press,  25  E.  Washington  St.,  Chicago. 

This  work  of  Dr.  Lydston's  should  be  very  popular  with  the  pro- 
fession. The  subject  is  one  of  special  interest  and  the  style  is  in 
keeping  with  this  author's  power.  His  historic  references  hold  one's 
attention  while  he  reviews  old  theories,  leading  to  the  newest  specu- 
lations. His  teachings  seem  to  us  sound  in  every  respect.  The  por- 
tion of  the  book  allotted  to  sex-gland  implantation  is  particularly 
interesting  and  satisfactory,  for  no  one  is  better  prepared  to  treat 
on  this  subect.  Dr.  Lydston  being  a  pioneer  in  this  work. 


PUBLISHERS'  DEPARTMENT  351 


Pepsin  is  undoubtedly  one  of  the  most  valuable  digestive  agents  of  our  Ma- 
teria Medica,  provided  a  good  article  is  used.  "Robinson's  Lime  Juice  and 
Pepsin"  (see  advertisement  in  tliis  issue)  we  can  recommend  as  possessing 
merit  of  high  order. 

The  fact  that  the  manufacturers  of  this  palatable  preparation  use  the  purest 
and  best  pepsin  and  that  every  lot  made  by  them  is  carefully  tested  before  offer- 
ing for  sale,  is  a  guarantee  to  the  physician  that  he  will  certainly  obtain  the 
good  results  he  expects  from  Pepsin. 

The  Catheter. 


The  Catheter  unskillfuUy  or  carelessly  employed  is  a  dangerous  instrument, 
and  before  its  use  it  is  better  where  there  is  retention  of  urine  to  resort  to  all 
palliative  measures  first,  as  hot  sitz  baths,  suppositories  of  belladonna  and 
opium,  hot  rectal  injections  and  colonic  flushings,  and  to  the  administration  of 
sanmetto  in  teaspoonful  doses  every  hour  for  first  three  or  four  hours  and  then 
every  two  hours  until  reasonable  time  for  relief.  Never  withdraw  the  entire 
amount  of  urine  at  once,  as  it  might  be  followed  by  hemorrhage  from  the  blad- 
der or  kidneys  or  a  complete  suppression  of  urine  ending  fatally.  Always  fol- 
low urethral  or  bladder  instrumentation  with  irrigation  or  injections  of  the 
milder  silver  salts,  and  the  administration  of  sammetto  to  soothe  and  relieve 
the  irritation  or  inflammation  of  the  urinary  canal. 


In  inflammatory  diseases  of  the  skin,  especially  where  volumetric  analysis 
shows  defective  urinary  elimination,  sanmetto  will  be  found  a  useful  remedy, 
owing  to  its  direct  action  on  the  kidneys. 


Cod  Liver  Oil  in  Chronic  Bronchial  Disorders. 


It  will  be  found  that  many  of  the  chronic  bronchial  inflammations  respond 
quickly  to  the  administration  of  Cord.  Ext.  01.  Morrhuae  Comp.  (Hagee). 
The  reasons  for  this  are  the  definitely  selective  influence  this  possesses  to  add 
strength  to  the  tissues  in  general,  the  combination  of  properties  serving  in  effi- 
cient manner  in  overcoming  the  chronic  bronchial  inflammations  so  common 
during  the  winter.  Cord.  Ext.  01.  Morrhuae  Comp.  (Hagee)  is  of  exceptional 
palatability,  a  feature  that  makes  it  of  unusual  value  with  women  and  children. 
Its  use  should  be  continued  throughout  the  winter  in  those  susceptible  to  bron- 
chial and  pulmonary  disease. 


Post  Operative  Quiet. 


For  the  purpose  of  relieving  nervous  irritability  and  bringing  about  rest  fol- 
lowing a  serious  operation,  the  surgeon  has  at  his  command  in  Pasadine  (Dan- 
iel) a  sedative  agent  of  the  greatest  usefulness  and  one  free  from  evil  effects. 
Pasadyne  (Daniel)  is  merely  a  distinctive  name  for  a  pure  concentrated  tincture 
of  passiflora  incarnata  and  is  a  product  that  has  stood  the  test  of  nearly  forty 


352      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

years.  The  advantages  possessed  by  Pasadyne  (Daniel)  lie  in  its  therapeutic 
potency  and  freedom  from  the  properties  that  cause  depression.  Surgeons  may 
depend  upon  it  to  secure  for  their  patients  the  rest  needed.  A  sample  bottle 
of  Pasadyne  may  be  had  by  addressing  the  laboratory  of  John  B.  Daniel,  Inc., 
Atlanta,  Georgia. 


"I  have  prescribed  large  quantities  of  tongaline,  doing  so  nearly  every  day 
for  many  years  with  most  satisfactory  results,  and  in  some  cases  the  successes 
have  been  really  phenomenal." 


An  Essential  Point  in  the  Therapeutics  of  Late  Syphilis. 


An  essential  point  in  the  therapeutic  management  of  late  syphilis  is  the  ad- 
ministration of  a  reliable  preparation  of  the  iodides,  through  which  the  patient 
is  insured  a  complete  iodine  action,  and  which  at  the  time  does  not  cause  any 
distressing  after-effect. 

With  many  extemporaneously  compounded  preparations  of  the  iodides  the 
initial  effect  is  favorable  but  shortly  the  evil  manifestations  of  iodism  become 
evident,  and  the  result  is  that  the  preparation  must  be  discontinued  to  the 
patient's  disadvantage. 

lodia  (Battle)  offers  the  physician  a  most  excellent  means  of  giving  the 
iodides,  and  makes  it  possible  to  secure  high  iodine  action  with  minimum  un- 
toward effect.  This  happy  feature  of  lodia  (Battle)  is  the  result  of  a  well- 
balanced  formula  and  the  employment  of  the  purest  ingredients,  factors  of  the 
utmost  importance.    Try  lodia  (Battle (  in  late  syphilis  and  note  results. 

The  Obstipation-Status-Autotoxemia  Syndrome  is  complex  in  its  etiology  as 
well  as  in  its  nosology.  Anything  that  interferes  with  the  calibre  of  the  gut, 
or  with  the  free  passage  of  intestinal  contents  through  the  tube,  results  in  a 
difficult  passage  of  the  bowel  contents  along  the  intestinal  canal— Obstipation. 

This  may  be  ptosis,  or  displacement  of  the  gut  at  some  point,  a  kink,  ab- 
normal sagging  of  suspensory  structures,  or  dislocation  of  some  part  of  the 
tube.  This,  together  with  abnormal  dryness  of  lack  of  lubricating  mucus,  due 
to  disturbance  of  the  intestinal  mucous  glands,  results  in  stagnation  of  the 
current,  stopping  in  many  instances,  a  damming  back  of  the  current— Stasis. 
or  chemical  action,  the  production  of  an  abnormal  amount  of  toxins  of  unusual 
power. 

As  a  result  of  these  influences,  opportunity  is  given  for  increased  bacterial 
virulence,  irritation  and  disturbance  of  the  filtering  or  protective  action  of  the 
mucous  membrane  and  resulting  absorption  of  increased  quantities  of  poison- 
ous material — auto-toxemia. 

As  a  result  of  so  many  factors  working  more  or  less  interdependently.  is  the 
establishment  of  the  Syndrome— a  complex  group  of  many  symptoms,  that  may 
simulate  almost  any  disease  or  diseased  condition  met  with  in  medicine. 

Furthermore,  these  conditions,  if  allowed  to  go  uncorrected,  may  and  often 
do,  aggravate  or  cause  serious,  even  fatal  disease. 

The  ideal  treatment  for  such  conditions  is  lubrication.     The  ideal  intestinal 

lubricant  is  interol  because  it  comes  closer  to  Nature's  own  lubricant mucus 

in  that  it  lubricates  without  stimulation,  irritation  or  enervation.  Being  non- 
absorbable, it  lubricates  "all  the  way."  On  account  of  its  characteristic^Zuferi- 
cating  body  it  efficiently  mixes,  spreads  and  clings  in  the  intestinal  tract,  and 
unless  too  much  is  administered  it  does  not  separate  from  the  feces  it  lubricates 
and  keeps  soft.    It  does  not  "ooze" — "per  se." 


NASHVILLE  JOURNAL 

—  or  — 

MEDICINE  AND    SURGERY 

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

Vol..  CXI.  DECEMBER,  1917.  No.  12 

Original  ffinmmuntraltnnfl 

THE  ULTIMATE  RESULTS  OF  THE  OPERATIVE  TREATMENT 
OF  MAMMARY  CANCER.-^ 


BY   DR.    HANS   LINDENBERG, 

Assistant  Physician  of  the  Clinic. 


(Translated  by  W.  T.  Briggs,  M.D.) 


Concluded  from  last  month. 
Our  treatment  ..f  mammary  cancer  during  the  time  under  consid- 
eration has  been  very  radical  and  will,  I  presume,  remain  so  for  a 
long  time.  During  the  last  few  years  the  Roentgen  rays  have  been 
used  after  operation  but  our  experience  is  not  yet  great  enough  to 
recognize  with  certainty  any  affect  from  the  rays.  The  indications 
for  operation  were  rather  comprehensive,  only  those  cases  having 
demonstrable  internal  metastases  and  some  of  the  cases  of  cancer  en 
cuirasse  being  refused  operation.  How  many  were  denied  operation 
I  can  not  say,  since  the  refusal  was  made  in  the  private  consultation 
hour  at  the  Polyclinic.  Neither  ulceration  nor  palpable  supra- 
clavicular glands  were  considered  contraindications.  Kuttner's 
view,  that  the  endothoracic  glands  are  already  involved  in  every 


*From  the  Surgical  Clinic  of  the  University  of  Rostock — Geh.  Medizinalrat 
Prof.  W.  Muller. 


354      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

case  in  which  the  supraclavicular  glands  are  palpable,  has  been  dis- 
proved by  Finsterer,  who  found  no  evidence  of  such  metastases  in 
three  postmortem  examinations.  Moreover  Finsterer  reports  three 
such  cases  who  have  lived  four  years  without  recurrence;  Gulecke 
and  Pilcher  also  report  cases;  however,  these  far-advanced  cases  are 
usually  incurable.  Advanced  age  in  itself  was  not  considered  a  con- 
traindication, indeed  twenty-five  of  our  cases  were  over  65,  and  6 
over  70.  However,  marked  cachexia  oftentimes  limited  the  extent 
of  the  operative  procedure.  For  instance,  supraclavicular  glands 
were  palpated  in  21  cases,  but  removed  in  only  14.  The  routine  re- 
moval of  the  supraclavicular  glands  as  advocated  by  Halstead,  was 
not  our  practice. 

In  regard  to  this  we  must  agree  with  Kuttner  in  the  opinion  that 
the  supraclavicular  glands  are  but  one  of  the  steps  by  which  cancer 
spreads,  and  that  the  operation,  however  radical  it  may  be,  but  sel- 
dom checks  the  further  spread  with  certainty,  whereas  the  dangers 
of  the  operation  are  certainly  increased.  In  our  cases,  therefore,  the 
supraclavicular  glands  were  removed  only  when  suspicially  palpa- 
ble and  the  general  condition  of  the  patient  promised  success.  Since 
the  middle  of  1904,  the  operations  at  the  Rostock  clinic  have  been 
performed  according  to  Rotter's  technic:  removal  of  the  affected 
breast  and  a  large  area  of  skin  along  with  the  contents  of  the  axilla 
and  both  pectorals;  oftentimes  Thiersch  skin  grafts  were  used  to 
close  the  skin  defect.  One  hundred  and  twenty  cases  were  operated 
in  this  manner.  However,  even  before  then  the  entire  pectoralis 
major  or  a  strip  of  it  was  removed.  In  five  cases  the  fascia  only 
was  removed. 

While  most  modern  authorities  advise  the  radical  operation,  others 
advise  careful  choice  of  operation.  Greenough  frankly  says:  incom- 
plete operations  give  far  better  results  in  mild  cases  than  do  the 
radical.  The  statistics  of  Heurtaux  in  Nantes,  who  merely  removes 
the  breast  and  cleans  out  the  axilla  and  of  whose  284  operated  cases, 
123  or  43.3  per  cent  were  still  alive  after  four  years,  seems  to  bear 
him  out  in  this  opinion.  Warren  gives  two  series  of  fifty  operated 
cases;  in  series  I  only  the  pectoral  fascia  (after  Volkmann),  was 
removed;  in  series  2,  Rotter's  technic  was  followed.  In  series  1  he 
obtained  fourteen  cures;  in  series  2  only  twelve  cures. 


ORIGINAL  COMMUNICATIONS  355 

What  were  the  results  in  our  1283  cases? 

From  the  operation  itself  not  a  single  patient  died,  but  thirteen 
died  as  a  result  of  the  operation.  That  is  7.1  per  cent.  This  is  a 
rather  large  percentage,  larger  than  we  usually  find  in  modern  sta- 
tistics. Bollinger  gives  1.5  per  cent,  Mauclaire  2  per  cent,  Wunderli 
2.5  per  cent,  P.  Schmidt  3  per  cent,  Finsterer  5.2  per  cent,  H.  Schmidt 
5.2  per  cent,  Schwarz  6.9  per  cent,  Dietrich  7.6  per  cent,  and  Salo- 
mon, 0.92  per  cent. 

This  may  be  due  to  the  fact  that  the  operation  in  the  Rostock  clinic 
is  performed  even  in  far  advanced  cases  regardless  of  the  effect  on 
statistics.  Among  the  operative  deaths  was  one  woman  with  dia- 
betes and  two  with  well-advanced  organic  heart  disease.  In  another 
case  both  breasts  were  carcinomatous  and  the  left  supraclavicular 
glands  were  removed.  A  septicaemic  case  died  from  decubitus  of 
the  sacrum,  while  the  operation  wound  healed  per  primam.  The 
fatal  cases  were: 

Erysipelas  bzw  sepsis 4 

Embolus    3 

Pneumonia    1 

Apoplexy     1 

Diabetes    (coma)    1 

Heart  weakness  1 

Myodegeneratio  cordis  1 

Endocarditis    1 

Of  these  fatalities,  four  occurred  in  1902  and  five  in  1907,  while 
the  remaining  four  were  spread  over  four  years.  This  alone  should 
demonstrate  how  chance  can  influence  statistics  if  the  total  number 
of  cases  is  small. 

The  results  in  the  other  cases  I  have  learned  in  the  following 
manner:  A  small  number  who  lived  in  Rostock  and  who 
returned  to  the  clinic,  I  was  able  to  examine  myself.  I  also  sent  a 
questionaire  to  the  physicians  who  had  sent  the  patients  for  opera- 
tion. This  brought  many  answers,  some  of  which  went  into  detail 
and  for  this  I  wish  here  to  express  my  thanks  to  my  confreres  as 
well  as  to  the  friends  and  magistrates  who  have  willingly  helped  me 
in  cases  where  information  through  the  physician  could  not  be  ob- 


356     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

tained.  In  this  way  I  received  satisfactory  information  in  176  cases; 
in  most  cases  not  only  in  regard  to  the  death,  but  also  its  cause  and 
the  condition  before  death.  Of  seven  patients  I  could  learn  nothing, 
partly  because  the  particulars  were  inexact,  partly  because  they  had 
emigrated  from  Mecklenburg. 

Naturally,  the  main  question  is,  when  can  a  cancer  of  the  breast 
be  considered  cured?  or,  when  can  one  at  least  have  some  reasonable 
hope  that  the  disease  is  absolutely  checked?  We  all  know  what 
Volkmann  said:  "One  year  after  the  operation  we  may  hope,  after 
two  years,  however,  we  may  have  some  assurance  that  there  will  be 
no  recurrence".  As  a  matter  of  fact  experience  teaches  that  by  far 
the  greatest  number  of  recurrences  as  well  as  metastases  appear  in 
the  first  year  after  operation,  a  much  smaller  number  in  the  second 
year,  but  even  in  the  third  year  there  are  a  certain  percentage  of  re- 
currences and  metastases;  because  of  this,  most  authorities,  even  as 
long  ago  as  the  eighties  of  the  last  century,  decided  that  three  years 
must  have  passed  before  a  cancer  case  should  be  considered  cured. 
During  the  last  two  decades  it  has  been  suggested  by  different  men — 
Steinthal,  Greenough — that  a  case  be  considered  cured  only  after 
five  years  have  passed  without  recurrence.  Mauclaire  even  goes  so 
far  as  to  hold  that  most  recurrences  occur  after  the  third  year,  but 
in  this  opinion  he  stands  alone. 

Steiner,  however,  says  that  with  his  cases  it  made  comparatively 
little  difference  whether  the  time  limit  were  three  or  five  years.  In 
order  to  throw  some  light  on  this  question  I  have  tabulated  our  re- 
sults according  to  both  the  three  and  five  year  period.  That  cure  is 
not  absolutely  certain  even  after  five  years,  the  many  known  cases 
of  late  recurrence  bear  ample  testimony.  We  have  had  four  cases 
of  late  recurrence  in  the  form  of  metastases  after  the  five  year  pe- 
riod; one  of  these  occurred  after  seven  years;  another  after  nine 
years  and  in  both  cases  the  metastases  were  in  the  vertebral  column. 
Forster  had  one  recurrence  respectively  after  10,  11,  13,  16,  and  20 
years;  Verneuil  one  even  as  late  as  the  33d  year.  Labhardt  made  an 
exhaustive  study  of  this  phase  of  the  subject.  Usually  the  late  re- 
currences show  up  in  other  organs,  and  without  postmortem  exami- 
nation and  painstaking  histologic  study,  there  is  no  way  of  telling 


ORIGINAL  COMMUNICATIONS  357 

whether  the  tumor  is  metastatic  or  a  new  neoplastic  growth.    In  this 
respect  two  of  our  cases  were  interesting. 

1.  Frau  0.  was  operated  in  1901  for  a  cancer  of  the  right  breast. 
In  1913  she  returned  with  a  tumor  of  the  coccyx  which  microscopi- 
cally proved  to  be  a  spindle-cell  sarcoma. 

2.  Frau  D.  in  1902  had  a  carcinoma  simplex  removed.  In  1911 
a  squamous-cell  carcinoma  developed  on  the  cervix  uteri. 

In  these  cases  the  tumors  were  histologically  different  types  of 
malignant  growth,  certainly  not  metastases. 

I  would  like  to  mention  just  here  that  we  have  had  several  cases 
which  had  previously  had  benign  tumors  removed  from  both  breasts. 

Seventy-seven  or  42.1  per  cent  of  our  operated  cases  had  recur- 
rence during  the  first  year.  The  true  significance  of  this  percentage 
can  be  realized  only  after  subtracting  from  the  total  number,  the 
number  of  those  who  have  had  no  recurrence;  this  latter  class  in- 
cludes those  who  died  as  a  result  of  the  operation  or  from  some  in- 
tercurrent affection,  as  well  as  those  rated  as  cured  and  those  whose 
fate  is  not  known. 

There  are  108  cases  which  are  either  dead  or  who  have  recurrences 
if  alive.  Seventy-seven  or  71.2  per  cent  of  these  recurrences  took 
place  in  the  first  year. 

12  or  11      per  cent  in  2  years. 

9  or  8.3  per  cent  in  3  years. 

4  or  3.7  per  cent  in  4  years. 

2  or  1.8  per  cent  in  5  years. 

1  or  0.9  per  cent  in  6  years. 

1  or  0.9  per  cent  in  7  years. 

1  or  0.9  per  cent  in  8  years. 

0  or  0      per  cent  in  9  years. 

1  or  0.9  per  cent  in  10  years. 

Almost  three-fourths  of  all  recurrences  appeared  in  the  first  year 
and  more  than  four-fifths  in  the  first  two  years.  Volkmann  was  not 
far  from  correct.  There  is  no  doubt  but  that  the  chances  of  perma- 
nent cure  increase  with  each  additional  year.  There  are  only  three- 
fourths  as  many  recurrences  in  the  third  as  in  the  second  year;  in 
the  fourth  there  is  only  a  scant  half  as  many  recurrences  as  in  the 


358     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

third,  and  again  about  half  as  many  in  the  fifth  as  in  the  fourth  year. 
Of  108  recurrences,  six  took  place  between  the  third  and  fifth  years. 
Later  recurrences  are  very  rare. 

I  will  now  discuss  in  detail  my  statistics.  I  will  rate  the  cures  ac- 
cording to  both  the  three  and  five  year  period.  According  to  the 
former  period  183  cases  will  be  considered,  according  to  the  latter, 
153.    The  cases  can  be  divided  into  two  groups: 

1.  Those  still  living  after  three  or  after  5  years. 

2.  Those  still  without  recurrence  after  three  or  five  years. 

How  to  deal  with  those  who  have  died  of  some  intercurrent  illness 
is  an  important  question  from  a  statistical  point  of  view.  They  can- 
not be  counted  with  the  recurrent  cases  and  they  certainly  should 
not  be  counted  among  the  cured  unless  they  lived  at  least  longer 
than  three  or  five  years  without  recurrence  and  died  from  some 
disease  diagnosed  other  than  carcinoma  by  a  physician. 

Taking  up  first  the  three  year  cure  class  our  figures  are  as  follows: 

Qf   183  cases 

No  trace  of 7  cases 

Dead  as  result  of  operation 13  cases 

Dead  of  some  intercurrent  disease 5  cases 

Dead  of  recurrence  or  metastases  in  1  year 54  cases 

Dead  of  recurrence  or  metastases  in  2  years 15  years 

Dead  of  recurrence  or  metastases  in  3  years 12  cases 

Therefore  are  living  after  three  years.. ..77  or  42.1  per  cent 

Living  but  with  recurrence 17 

Consequently  there  are  living  without  recurrence  after  three  years 
60  or  32.7  per  cent. 

For  the  five  year  class  we  can  consider  only  those  cases 

operated  previous  to  and  including  1908  or 15.3 

No  trace  of  ' 

Dead  as  result  of  operation 12 

Dead  of  some  intercurrent  disease 8 

Dead  from  recurrence  in  the  first  3  years 67 

Dead  from  recurrence  in  the  first  4  years 6 

Dead  from  recurrence  in  the  first  5  years 5 

Therefore  are  living  after  5  years 48  or  31.4  per  cent 

Living  but  with  recurrence 5 


ORIGINAL  COMMUNICATIONS  359 

Consequently  there  are  living  without  recurrence  after  5  years 
43  or  28  per  cent. 

Of  the  43  cures  in  this  group,  3  had  recurrences  shortly  after  the 
operation,  which  were  removed  and  did  not  recur  within  the  five 
year  limit. 

If  merely  the  figures  are  considered,  the  statistics  show  the  differ- 
ence between  the  3  and  5  year  cures  is  only  5  per  cnt.  But  we  must 
not  lose  sight  of  the  fact  that  the  statistics  of  the  five  year  group 
must  include  12  of  the  13  operation  deaths,  that  all  those  not  traced 
and  a  very  much  larger  number  dying  of  intercurrent  diseases  must 
also  be  included.  I  might  have  found  still  other  sources  of  error 
from  a  statistical  point  of  view,  had  I  made  the  attempt.  Suffice  it 
to  say,  the  real  difference  amounts  to  3  per  cent  at  most;  so  taken 
all  in  all  it  makes  but  little  difference  whether  the  3  or  5  year  period 
is  used.  Certain  it  is  that  none  of  our  patients  are  sure  of  no  recur- 
rence; even  among  those  who  lived  longer  than  5  years,  3  died  later 
of  cancer  and  one  still  lives  but  with  metastases.  That  means  9.3 
per  cent.  So  we  must  modify  Volkmann's  dictum  as  follows:  After 
2  years  we  can  hope,  after  3  years  we  can  hope  more,  after  5  years 
we  can  have  some  assurance  that  the  growth  will  not  recur. 

Let  us  now  consider  in  more  detail  the  cured  cases.  The  first 
question  is:  were  those  patients  we  operated  successfully  of  any 
special  type,  was  the  disease  less  advanced,  finally  was  the  type  of 
neoplasm  less  malignant.  It  is  indeed  a  true  saying,  "There  is  a 
difference  between  'cancer'  and  'cancer';  and  in  comparing  the  can- 
cers according  to  the  clinical  stage  and  the  microscopical  findings, 
we  were  again  impressed  with  the  truth  of  this  saying. 

The  patients  who  now  have  no  recurrence,  to  which  group  I  add 
those  dead  of  some  intercurrent  illness  who  lived  three  years  without 
recurrence,  number  fifty  and  can  be  separated  into  groups  as  fol- 
lows: 

1.  To  the  first  stage  (movable  tumor,  no  glandular  involvement. .24 

2.  To  the  second  clinical  stage    (glandular  involvement,  tumor, 
movable;  or  no  glandular  involvement  but  the  tumor  fixed). ...22 

3.  To  the  third  clinical  stage  (glandular  involvement  and  tumor 
fixed)    4 

4.  To  the  fourth  clinical  stage  (supraclavicular  glandular  involve- 
ment)      0 


360     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

The  full  significance  of  these  figures  is  grasped  when  we  compare 
them  to  the  whole  number  in  each  group. 

Stage  1.  35  cases 24  cures  or  68.5  per  cent 

Stage  2.  81  cases 22  cures  or  27.1  per  cent 

Stage  3.  53  cases 4  cures  or    7.6  per  cent 

Stage  4.  14  cases 0  cures  or    0     per  cent 

Therefore,  if  the  cases  comes  to  us  in  the  beginning  of  the  clinical 
development  of  the  tumor  (and  this  time  does  not  necessarily  cor- 
respond to  the  time  the  tumor  has  been  present)  there  is  a  chance 
of  a  cure  in  66  per  cent  of  cases.  If,  however,  the  tumor  has  already- 
reached  the  first  stage  of  its  spread  through  the  body,  our  chances 
sink  to  less  than  33  per  cent,  still  further  spread  cuts  our  chances  of 
cure  to  8  per  cent,  and  after  the  supraclavicular  glands  are  affected 
our  chances  are  nil.  Not  a  single  one  of  our  cases  with  supraclav- 
icular glandular  involvement  lived  longer  than  21/^  years  without  re- 
currence. However,  the  above  mentioned  cures  of  such  cases  by  Fin- 
ister,  Gulecke  and  Pilcher,  will  encourage  us  to  continue  to  remove 
these  glands,  since  a  prolongation  of  life  may  thereby  be  obtained. 

The  histological  diagnoses  in  our  cured  cases  was: 

Adenocarcinoma 10  cures  from  31  cases  or  32.3  per  cent 

Carcinoma  simplex. 24  cures  from  96  cases  or  28.1  per  cent 

Scirrhus 10  cures  from  40  cases  or  25     per  cent 

Medullary  carcinoma 2  cures  from    4  cases  or  50     per  cent 

Colloid  carcinoma 1  cure    from    5  cases  or  20     per  cent 

The  last  two  percentages  are  naturally  of  little  value. 

Adenocarcinoma  was  the  type  most  frequently  found  in  the  first 
stage;  a  comparison,  however,  between  carcinoma  simplex  and  scir- 
rhus is  very  interesting.  While  21  per  cent  of  the  simple  carcino- 
mata  and  only  10  per  cent  of  scirrhus  belonged  to  the  first  stage,  and 
the  former  would  seem  to  offer  especially  good  chances  of  cure,  yet 
we  see  that  the  cures  are  almost  the  same.  Probably  this  is  due  to 
the  fact  that  scirrhus  often  extends  rapidly  to  the  glands  but  for  the 
most  part  grows  slowly.  Let  us  compare  with  the  above  some  of 
the  results  of  other  operators.  Halstead's  figures  also  show  that 
adenocarcinoma  offers  the  best  prognosis,  since  he  obtained  75  per 
cent  of  cures  with  this  type,  48  per  cent  with  medullary  cancer,  46 


ORIGINAL  COMMUNICATIONS  361 

per  cent  and  and  22  per  cent  respectively  for  localized  and  diffuse 
scirrhus. 

With  adenocarcinoma  Warren  had  66  2-3  per  cent  cures,  but  only 
three  cases.  Of  26  cases  of  carcinoma  simplex  6,  or  23  per  cent 
were  cured.  With  scirrhus  he  had  43  per  cent  cures.  He  is  the  only 
author  who  report  a  large  number  of  medullary  cancers;  he  had 
40  with  only  3  or  7.5  per  cent  cured.  We  can  not  compare  the  cures 
distributed  according  to  type  of  growth  in  Salomon's  cases  to  ours, 
since  he  studied  the  results  from  an  entirely  different  standpoint. 
However,  he  also  finds  that  adenocarcinoma  offers  the  best  progno- 
sis and  the  cures  is  given  in  detail  in  only  a  few  articles.  The  clini- 
cal condition  of  the  patient  counts  most.  Almost  everywhere  we  find 
the  statement  that  the  largest  percentage  of  cures  occurs  in  cases 
showing  no  glandular  involvement  at  operation.  Some  of  these  are 
as  follows: 

Author  Without  glandular  involvement  With  involvement 

Salomon    85  per  cent  

Villars  and   Monniquaud  71  per  cent  21  per  cent 

Halstead    70  per  cent  24  per  cent 

Hildebrand    34.6  per  cent  18.4  per  cent 

Gebele   99  per  cent  

Sprengel    20  per  cent  9  per  cent 

Steinthal    69-85  per  cent  26.5-32  per  cent 

Furthermore,  the  authors  who  do  not  give  the  exact  figures,  still 
emphasize  the  better  prognosis  in  cases  without  glandular  involve- 
ment. This  advantage  can  not  be  counterbalanced  by  the  most  radi- 
cal operation  in  advanced  cases. 

I  would  now  like  to  discuss  on  a  basis  of  the  material  at  our  clinic 
whether  as  a  rule  the  radical  operation  is  an  improvement.  Two 
articles,  one  by  Stephan  the  other  by  Schroeder,  discussing  the  cases 
in  the  Rostock  Clinic  from  1875-1900,  have  been  published.  In  all 
there  were  347  cases.  In  the  first  50  cases,  discussed  in  Stephan's 
article  and  operated  while  Trendelenburg  had  charge  of  the  clinic, 
as  a  rule  only  the  breast  was  removed,  the  axilla  being  cleaned  only 
when  the  glands  were  palpable.  There  were  8  cures  or  16  per  cent, 
and  in  5  of  these  the  axilla  was  not  invaded  at  operation.  (Another 
demonstration   of  the  prognostic   significance   of  axillary   involve- 


362     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERV 

ment.)  Marelung  then  commenced  the  routine  dissection  of  the 
axilla  and  in  addition  removed  the  fascia  of  the  pectoralis  major 
and  Garre  went  further  in  that  he  removed  a  superficial  layer  of  this 
muscle.  Schroeder's  statistics  show  21.5  per  cent  3  year  cures.  It 
is  but  natural  to  attribute  this  11  per  cent  increase  in  cures  to  the 
regularly  carried  out  more  radical  operation.  Most  of  the  cases  tab- 
ulated by  Schroeder  occurred  after  the  dawn  of  antisepsis;  only  in 
the  first  50  cases  was  the  mortality  greater  than  ours,  e.  g.  10  per 
cent.  Later  it  was  only  4.6  per  cent.  The  better  success  was  prob- 
ably due  to  an  improved  technic.  The  above  comparison  is  signifi- 
cant since  the  same  class  of  material  was  treated. 

Now  I  would  like  to  discuss  an  objection  to  the  operative  technic 
of  Rotter,  namely,  that  the  usefulness  of  the  arm  is  impaired.  This 
point  was  incorporated  in  my  questionaire  and  in  almost  every  case 
the  reply  was  explicit.  The  patients  who  could  not  use  the  arm  suf- 
fered for  the  most  part  from  an  oedema  which  retarded  the  return 
flow  of  the  lymph  and  increased  the  weight  of  the  limb.  Of  the  60 
three  year  cures,  only  four  suffered  from  limitation  of  motion  of  the 
arm.  As  to  whether  Rotter's  technic  gives  better  results  in  regard 
to  local  recurrences,  I  am  sorry  to  say  I  can  give  no  definite  answer, 
since  Schroeder  does  not  take  up  this  point  in  detail  and  our  statis- 
tics are  also  defective  in  this  respect.  The  answers  of  my  confreres 
have  not  explicitly  stated  whether  the  recurrences  were  in  the  scar 
or  near  it.  If  only  the  cases  are  considered  in  which  the  answers 
were  exact,  we  find  that  recurrences  usually  occurred  in  the  scar. 
Recurrences  occurred  in  the  scar  in  85  or  45  per  cent  of  our  cases. 
Seventeen  patients  had  a  metastasis  as  well  as  local  recurrence.  We 
have  not  been  as  successful  in  this  respect  as  Halstead  or  Rotter,  the 
former  having  local  recurrence  in  only  11  per  cent  of  his  cases. 
Forty-three  of  our  patients  were  reported  with  metastasis  and  six  of 
these  had  several.    The  sites  of  the  metastases  were  as  follows: 

General  carcinomatosis  9 

Pleura  and  lungs 12 

Spinal   column   4 

Femur    4 

Brain   2 

Liver    8 


ORIGINAL  COMMUNICATIONS  363 

Stomach     4 

Bowel    2 

Peritoneum    1 

Other  breast  3 

Opposite  axilla  3 

We  operated  52  patients  for  recurrence.  In  three  of  these  cases 
the  second  breast  and  in  three  the  opposite  axilla  was  operated. 
Three  cases  lived  more  than  5  years  after  the  operation  for  recur- 
rence.    One  of  these  deserves  special  mention. 

Twelve  years  Frau  L.  had  a  cancer  of  the  left  breast  which  was 
removed  by  the  radical  operation;  in  the  first,  and  again  in  the  sec- 
ond year  after  operation,  local  recurrences  were  removed.  Four 
years  ago  after  the  first  operation,  carcinoma  developed  in  the  right 
breast.  This  was  also  removed  by  the  radical  operation.  After  this 
the  patient  lived  seven  years  without  recurrence.  During  the  sum- 
mer of  1911  a  kyphosis  developed  in  the  lumbar  portion  of  the 
spinal  column;  aside  from  some  neuralgic  pains  in  the  legs  there 
were  no  symptoms  until  April,  1913,  when  sudden  paralysis  of  both 
legs  supervened.     Frau  L.  is  still  alive  (March,  1914.) 

In  conclusion,  I  would  like  to  briefly  recapitulate  our  experiences. 

1.  Even  though  in  any  given  case  we  can  not  say  with  assurance 
that  cancer  of  the  breast  will  not  recur,  still  recurrences  after  the 
fifth  year  are  rare.  As  a  matter  of  fact  there  is  a  great  probability 
of  permanent  cure  even  after  the  third  year;  32.7  per  cent  of  our 
patients  lived  longer  than  3  years,  28  per  cent  longer  than  5  years. 
Metastases  developed  in  4  cases  even  after  the  5  year  limit.  This 
means  that  metastases  occur  in  9.4  per  cent  of  the  "cured." 

2.  The  cases  without  axillary  involvement  offer  the  best  prognosis 
(68.5  per  cent  cures).  They  are  composed  of  (a)  early  discovered 
carcinomata  of  all  types,  and  (b)  cancers  which  spread  slowly. 
Adenocarcinoma  seems  to  be  the  most  common  growth  under  this 
head. 

3.  By  using  Rotter's  technic,  the  end  results  have  apparently  been 
improved. 

4.  Every  case  should  be  operated  as  soon  as  possible. 

I  submit  below  for  comparison  the  results  of  other  authors  whose 
figures  are  based  on  the  three  year  limit;   in  cases  where  another 


364      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


limit  has  been  chosen,  this  is  noted  under  "remarks"  in  the  table. 
In  cases  where  the  names  are  marked  with  an  arterisk,  I  have  not 
given  the  author's  figures  but  have  changed  them  according  to  the 
suggestions  of  Cheyne.  I  agree  with  him  in  thinking  it  an  error  to 
compare  the  operative  cures  to  the  total  number  of  operated  cases 
in  making  up  statistics  and  that  only  those  cases  which  have  lived 
more  than  three  years,  should  be  tabulated.  Again,  some  authors 
who  have  successfully  traced  only  a  part  of  their  cases,  in  making  up 
their  percentages,  simply  disregard  those  not  heard  from.  Since  in 
my  opinion  it  is  easier  to  get  information  about  the  living  than  about 
those  who  have  been  dead  for  some  time,  the  omission  of  the  above- 
mentioned  cases  makes  the  statistics  too  favorable.  In  cases  where 
this  error  was  especially  apparent,  I  have  made  a  marginal  note. 

The  figures  show  by  comparison  that  for  the  most  part  the  results 
have  improved  during  the  last  20  years.  The  variety  of  the  sources 
of  the  material,  however,  precludes  the  possibility  of  determining 
the  average  percentage  of  cures  in  breast  carcinomata. 

No.  Per  ent      Remarks 

1.  Winifarter,    1878,    Zurich.    Wien,    Willroth 89  9.0* 

2.  Henry,   1879    (Breslau,    Fischer) 86  15.0* 

3.  Oldekop,   1879    (Kiel,  Esmarch) 171  14.0* 

4.  Sprengel,    1881    (Halle,   Volkmann) 131  11.0 

5.  Schmidt,  H.,  1887,(Berlin,  Augusta  Hosp.,  Kuster  132  15.0* 

6.  Rotter.   1887    (Berlin,   V,   Bergmann) 114  32.0     Only  42   cases   considered. 

7.  Hildebrandt,    1887    (Cottingen,    Konig) 136  23.0* 

8.  Schmidt.   A.   B.,   1889    (Heidelberg,    Czemy) 83  9.6     On    5-year    cure    basis, 

9.  Fink,    1889    (Prag,    Gussenbauer) 253  16.7        9  per  cent. 

10.  Poulsen,    1891    (Copenhagener,    Stadt    hospital) 325  20.0 

11.  Dietritch,    1892    (Strassburg,    Lucke) 95  16.0                                             , 

12.  Horner.    1884    (Zurich,   jeronlein) 144  19.4 

13.  1896   (Greifswald,  Helperich)    98  28.5 

14.  Meier,    1896   Bern,    Kocher) 212  31.0 

15.  Jones  anr  Piatt,    1895    (Manchester  Royal   Infrm...  55  18.0     5-year   cure,    11.5  per   cent. 

16.  Cheyne,   W.,   1896    (King's   College   Hos.,  London  21  57.0t 

17.  Mahler,    1900    (Heidelberg,    Czerny) 133  21.0 

18.  Gebele,    1901    (Munchen,   Argerer)    189  16.9 

19.  Gulecke,    1901    ((Berlin,    v,    Bergmann) 382  28.8     322   not   traced. 

20.  Rosenstein,    1901    (Wien,   v,   Eiselberg) 145  22.7 

21.  Barker,    1900    (Univ.    College   Hosp.,   London) 86  33.7     5-year  cure,    16.2   per  cent. 

22.  Schmidt,   P.,   1904    (Gottingen,   Ect.   Braur) 162  28.3     53  not   traced. 

23.  Meissl,    1904    (Wien)    247  18.0 

24.  Schwarz,    1905    (Graz,   v.    Hacker) , 

25.  Schroder,    1905    (Rostock,    Trendelenburg,    Made-  186  14.5 

lung    and     Garre) 347  21.5 

26.  Wunderli,   1906    (Spital  St.   Gallen) 183  14.0 

27.  Steiner,     1906     (Budapest,     DoUinger) 108  16.0 

28.  Scheu,    1907    (Breslau,    v.,    Mikulicz) 233  20.2 

29.  Halstead,  1907   (Johns  Hopkins  Hosp.,  Baltimore)   232  38.8     5-year  cure,   32.3  per  cent. 

30.  Finsterer,    1907    (Wien,    v„    Hochenegg) 606  15.3 

31.  Greenough,    1907    (Mass.   enl.    osp.,    Boston) 376  18.0     40   not    traced. 

32.  Ochsner,    1907     (Augustana    Hosp.,    Chicago) 164  31.5 

33.  Jacobson,    1907     (Syracuse,    N.    Y.) 71  49.0 

34.  Oliver,    1907    (Cincinnati,    Ohio) 35  34.3 

35.  Cabot,    1907    (Boston,    Private    Practice) 42  33.3 

36.  Depage,    1908    (Belgium)    62  48.0 


ORIGINAL  COMMUNICATIONS  365 

37.  Villars   and    Monniquaud,    1908    (Lyon) 50  54.0 

38.  Le   Dentu,    1908    (France) „ 47  47.9    5-year  cure,  32.2  per  cent. 

39.  Heurteaux,    1908    (antes) 284  43.3     4-year  basis. 

40.  Ribera,   Y   Sans,    1908    (Madrid) 135  40.0 

41.  Borelius,    1908    (Lund) 77  35.0 

42.  Jonnesou,     1908     (Bukarest) 66  30.0 

43.  Dollinger,     1908     (Budapest) -     40  6.0     Halstead    operation. 

44.  Warren,    1909     (England) 100  30.0t 

45.  Leech,    1910     (England) 66  21.0 

46.  Pans.    1910    (Copenhagen)    70  31.4    5-year  cure,   18.8 

47.  Steinthal,    1912    (Kathariner,    Spit,,    Stuttgart 200  30.0 

48.  Schwarzkopt,    1912    (Prag,    Wolffler 269  20.8    57  not   traced. 

(Innsbruck,    Schloffer)    66  27.7 

(Innsbruck,    Private    Clinic,    Schloffer)      14  42.8 

49.  Salomon,  1913   (Berlin,  Bier)   212  33.5 

50.  Lindenberg    (Rostock,   W.   Muller) 183  32.7    5-year   cure,   28   per   cent. 

tin   the  original   one  name  omitted   opp.  which  stood  figures  72-24.7  operation   of  Halstead. 


Extrarta  frnm  H^amt  attJi  Jorrtgn  Sflurnala 


SURGICAL 


Residual  Nitrogen  in  the  Blood  with  Surgical 
Kidney  Disease, 


Sabroe  remarks  that  none  of  the  functional  tests  for  the  kidneys, 
with  stains,  experimental  polyuria  or  determination  of  the  freezing 
point,  have  proved  unfailingly  reliable.  They  all  overlook  the  vital 
point  that  the  functioning  of  the  kidneys  at  a  given  moment  is  not 
necessarily  the  criterion  for  their  average  functional  performance. 
The  most  reliable  information  as  to  the  functional  capacity  of  the 
kidneys  seems  to  be  afforded  by  the  urea  content  of  the  urine  taken 
from  each  ureter  separately.  Positive  findings  are  strong  evidence 
in  favor  of  operability,  but  the  reserve  is  by  no  means  the  case.  With 
surgical  tuberculosis,  there  is  always  a  possibility  that  the  part  of 
the  kidney  which  it  is  proposed  to  remove  may  in  reality  be  the  very 
tissue  responsible  for  the  approximately  normal  functioning.  Deter- 
mination of  the  residual  nitrogen  in  the  blood  as  a  test  for  the  func- 
tional capacity  of  the  kidneys,  Sabroe  declares,  is  of  no  clinical 
value  in  estimation  of  surgical  kidney  affections,  as  the  rise  in  the 


366     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

residual  nitrogen  content  does  not  occur  until  so  late  in  the  disease 
that  the  clinical  findings  alone  tell  the  story  by  that  time.  This  con- 
clusion is  based  on  study  of  eight  patients  with  tuberculous  lesions 
in  the  urinary  passages,  ten  with  nontuberculous  lesion  given  opera- 
tive treatment,  and  eight  with  full  details,  filling  thirteen  pages,  all 
confirming  the  disappointing  verdict. — The  Jour,  of  the  Am.  Med. 
Asso. 


MEDICAL 


Damages  for  Result  of  Exposure  to  Cold. 


A  physician  was  summoned  to  attend  a  patient  on  a  cold  night  in 
March.  The  journey  of  about  fifteen  miles  was  made  in  a  buggy. 
On  returning,  at  an  exposed  point  on  the  road  he  was  prevented  from 
crossing  the  railroad  tracks  by  a  standing  freight  train  for  about  fifty 
minutes.  He  was  in  good  condition  when  he  stopped,  but  after  about 
fifteen  minutes  he  discover  that  he  was  beginning  to  feel  numb  and 
chilled.  By  the  time  the  train  moved  he  had  become  so  affected  by 
cold  that  he  was  no  longer  able  to  grasp  the  lines,  and  was  com- 
pelled to  wrap  them  around  his  wrists  and  arms  in  order  to  control 
his  team.  As  a  result  of  the  exposure  he  contracted  articular  rheu- 
matism and  sufferd  from  this  disease  for  a  long  time.  In  an  action 
against  the  railroad  to  recover  damages  it  was  held  that  he  was  en- 
titled to  recover,  and  judgment  for  $875  was  affirmed. — Med.  Record. 


OBSTETRICAL 


Early  Ectopic  Pregnancy  Complicated  by  Appendicitis. 


Dr.  Stein  reported  this  case.  He  stated  that  the  patient  was  26 
years  of  age.  Her  previous  history  was  negative.  She  had  had  one 
child,  seven  years  ago.  On  the  day  previous  to  admission  to  the 
Harlem  Hospital  she  was  suddenly  seized  with  severe  pain  in  the 
right  lower  abdomen,  accompanied  by  pains  in  the  vagina.     Her 


EXTRACTS  FROM  JOURNALS  367 

menstruations  had  always  been  regular  up  to  the  last  time.  She  had 
finished  her  last  menstruation  about  three  weeks  before.  Examina- 
tion showed  bleeding  from  the  vagina  and  the  uterus  somewhat  en- 
larged and  soft.  There  was  marked  tenderness  extending  over  the 
right  lower  abdomen  and  up  as  far  as  McBurney's  point.  The  right 
adexna  could  not  be  definitely  made  out.  There  was  no  tissue  dis- 
charged from  the  uterus.  The  patient  was  then  transferred  to  the 
private  building  of  the  German  Hospital  for  further  observation. 
Being  unable  to  make  a  definite  diagnosis  in  two  or  three  days,  a 
probable  diagnosis  of  ectopic  pregnancy  or  subacute  appendicitis 
was  made,  although  the  definite  signs  of  appendicitis  (rigidity  of 
the  muscles  and  rebound  upon  withdrawal  of  the  hand  after  pres- 
sure) were  not  present.  On  the  third  day  the  patient  had  another 
attack  of  severe  pain  and  operation  was  decided  upon.  A  curettage 
preceded  the  laparotomy.  Some  apparently  decidual  tissue  was  re- 
moved. A  transverse  incision  was  made.  Upon  opening  the  abdo- 
men the  right  tube  was  found  to  be  about  as  thick  as  a  thumb  with 
blood  oozing  from  the  fimbrian  end.  There  was  marked  adhesions 
with  omentum,  and  also  with  the  appendix.  The  right  tube  and 
ovary  were  lying  very  high  on  the  ilium.  This  location  seemed  to 
be  reason  for  their  inability  to  locate  and  properly  palpate  the  right 
adnexa.  The  right  tube  was  then  removed  in  toto,  whereas  the  right 
ovary  was  left  behind.  The  stump  of  the  tube  was  secured  with 
chromic  catgut  suture.  The  appendix  which  was  adherent  to  the 
tube  and  was  also  subacutely  inflamed  and  thickened  with  dilated 
vessels.  It  was  removed  and  the  stump  buried  with  silkworm  suture. 
The  operation  required  twenty  minutes.— Mec?ica/  Record. 


368     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


i£btt0ml 


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The  Double  Standard  for  the  Sexes. 


Secretary  Daniels,  in  an  address  at  the  recent  Clinical  Congress 
of  Surgeons  in  Chicago,  appealed  to  the  profession  "to  end  the  false 
double  standard  of  the  two  sexes." 

He  gave  some  very  depressing  statistics  regarding  the  great  preva- 
lance  of  venereal  diseases  among  enlisted  men.  For  instance:  "Dur- 
ing the  last  statistical  year  men  of  the  American  Navy  lost  141,387 
days'  sickness  from  a  small  group  of  absolutely  preventable  diseases 
contracted  by  sin."  He  went  on  to  say  the  remedy  was  continence 
and  that  the  medical  profession  should  never  cease  preaching  con- 
tinence and  further  "Continence  is  no  longer  a  matter  of  morals 
only,  though  it  must  be  enforced  as  the  cardinal  doctrine  of  morals. 
It  has  come  to  be  seen  as  having  its  base  in  the  great  law  of  Nature. 
New  truths  must  take  the  place  of  ancient  lies.  We  know  by  the 
testimony  of  science  that  there  is  no  foundation  for  a  double  stand- 
ard for  the  two  sexes.  The  lie  that  has  lived  so  long  must  be  driven 
out  by  the  truth." 

We  heartily  agree  with  Mr.  Daniels  in  his  desire  to  eliminate  ven- 
ereal diseases  and  immorality  from  the  Army  and  Navy  and  civil 
life  as  well.    And  practically  all  physicians  agree  with  him. 

However,  we  can  not  agree  with  Mr.  Daniels  in  the  statement  that 
continence  has  its  basis  in  the  great  law  of  Nature,  since  it  is  a  scien- 
tific fact  that  most  male  animals,  as  well  as  man  himself,  mastur- 


EDITORIALS  369 

bate  if  so  situated  that  sexual  gratifications  in  the  normal  way  is  im- 
possible. Furthermore,  for  our  own  enlightenment  we  would  like 
to  know  where  Secretary  Daniels  obtained  "the  testimony  of  science 
that  there  is  no  foundation  for  the  double  standard  for  the  two 
sexes."  Science  teaches  us  that  throughout  the  animal  kingdom — 
and  this  includes  man — the  sexual  instinct  is  greater  in  the  male  than 
in  the  female  and  that  certain  animals  during  the  rutting  season  are 
absolutely  under  the  control  of  the  sexual  instinct,  even  hunger  be- 
comes secondary.  Even  man  himself  experiences  an  annual  peri- 
odical increase  in  sexual  desires  in  the  spring  of  the  year. 

Since  science  teaches  that  sexual  desire  is  greater  in  the  male, 
science  must  also  grant  that  there  is  more  reason  why  men  should 
gratify  this  instinct. 

But  even  if  we  deny  this  scientific  truth,  as  apparently  Mr.  Dan- 
ils  would  have  us  do,  there  is  still  another  reason  for  the  double 
standard  that  we  can  not  gainsay.  This  reason  is  the  fact  that  only 
one  of  the  two  sexes  can  become  pregnant.  Civilization  may  change 
the  instincts  so  that  man  and  woman  will  be  more  on  a  par  in  sexual 
desire,  but  the  highest  imaginable  civilization  can  not  make  man  a 
child-bearing  animal.  Since  this  is  so  we  must  always  expect  a  dou- 
ble standard  in  sexual  matters.  Even  with  sexual  instincts  so  differ- 
ent in  the  two  sexes  as  they  are  today,  there  would  hardly  be  a  ques- 
tion of  a  double  or  single  sex  standard  were  men  subject  to  preg- 
nancy as  are  women.  Immoral  sexual  intercourse  does  not  brand 
the  male  transgressor  except  perhaps  with  disease.  And  venereal 
disease  is  a  secret  disease.  Unless  unfortunate  enough  to  contract 
disease  the  male  usually  goes  forth  scot  free,  whereas  the  female 
transgressor  sooner  or  later  conceives.  After  conception  she  either 
becomes  a  criminal  or  an  outcast. 

Even  though  society  would  treat  the  male  transgressor  as  severely 
as  it  treats  the  female,  there  would  still  be  a  different  standard,  since 
society  could  not  often  know  which  males  had  fallen  from  grace. 
Therefore  we  must  look  upon  instinct  and  pregnancy  as  two  scientific 
reasons  for  the  double  standard  in  sexual  matters. 

We  can  not  with  Secretary  Daniels  say,  "The  lie  that  has  lived  so 
long  must  be  driven  out  by  the  truth",  since  we  honestly  believe  there 
are  even  more  reasons  than  those  given  above  for  the  double  stand- 


370      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

ard.  But  because  we  recognize  the  truth  we  are  none  the  less  in  ac- 
cord with  all  earnest  advocates  for  continence  in  single  men.  Such 
continence,  however,  is  not  to  be  obtained  by  flowery  speeches  nor 
by  varnishing  over  the  truth,  but  only  by  action  along  sociological 
and  economical  as  well  as  moral  lines  and  rather  by  control  of  im- 
morality in  women  than  in  men.  Not  control  of  immorality  by  mu- 
nicipal governments,  abolishing  the  red  light  districts  and  other  or- 
dinances of  that  type,  but  the  saving  of  girls  before  they  fall. 

This  can  only  be  done  by  truthful  sex-education,  by  a  living  wage 
for  young  men  and  women  based  on  the  modern  cost  of  living  and 
not  the  cost  of  living  a  hundred  years  ago,  by  dissemination  of 
knowledge  of  preventives,  and  finally  by  much  more  drastic  punish- 
ment of  seducers  and  white  slavers  than  we  now  have. — W.  T.  B. 


Cases  of  Pneumonia  Should  be  Reported  and  Quarantined. 


In  view  of  these  facts  it  is  clear  that  a  vigorous  public  health  cam- 
paign must  be  directed  by  communities  against  the  ravages  of  lobar 
pneumonia.  Some  health  departments  have  already  taken  a  forward 
step  in  declaring  lobar  pneumonia  a  reportable  disease,  like  measles 
and  scarlet  fever,  requiring  visitation  by  the  health  departments  to 
insure  quarantine.  This  is  a  new  idea  for  most  people.  There  are, 
undoubtedly,  millions  of  persons  in  the  country  who  would  not  go 
into  a  house  where  there  was  measles,  scarlet  fever,  whooping-cough 
or  diphtheria,  but  who  would  not  hesitate  to  go  into  a  sick  room 
where  there  was  a  case  of  acute  lobar  pneumonia.  Nevertheless,  the 
best  medical  authorities  have  shown  that  this  disease  is  extremely 
infectious,  and  that  those  who  are  stricken  with  it  have  a  worse 
chance  of  recovering  than  if  they  had  any  of  the  infectious  diseases 
mentioned. 

More  states  and  cities  should  require  that  physicians  report  every 
case  of  lobar  pneumonia  and  must  enforce  this  requirement.  Com- 
munities can  also  help  by  checking  the  nasty  habit  of  spitting  in 
public  places,  which  is  probably  the  most  fruitful  method  of  spread- 
ing the  germ  of  pneumonia. 

The  form  of  pneumonia  known  as  broncho-pneumonia  is  also  a 
serious  factor  in  the  death  rate,  especially  of  young  children;  but 


EDITORIALS  371 

must  not  be  confused  with  the  infectious  disease  which  health  de- 
partments are  now  taking  steps  to  quarantine. 


Every  Doctor  in  the  Medical  Reserve  Corps. 


What  an  ideal  situation  it  would  be,  if  every  doctor  in  the  United 
States  who  is  mentally,  physically  and  morally  fit,  was  in  this  corps. 

The  time  is  coming,  and  in  the  immediate  future,  when  the  Medi- 
cal Reserve  Corps  of  the  Army  niust  be  immensely  augmented,  and 
so  as  to  enable  th  Surgeon  General  to  have  at  his  command  for  im- 
mediate assignment,  as  conditions  demand,  a  sufficient  number  of 
trained  medical  officers,  let  us  take  the  above  thought  seriously. 

We  all  know,  from  past  history,  the  conserving  value  of  an  effi- 
cient medical  corps,  and  this  means  number,  as  well  as  training. 

A  statement  made  by  one  high  in  authority  in  the  Surgeon  Gen- 
eral's Office,  "that  our  fighting  forces  would  be  deciminated  by  sick- 
ness and  casualties  in  six  months,  were  it  not  for  an  efficient  Army 
Medical  Corps,"  clearly  emphasizes  the  importance  of  every  doctor 
in  the  United  States,  meeting  the  requirements  above  referred  to, 
accepting  a  commission  in  the  Medical  Reserve  Corps  of  the  United 
States  Army. 

The  struggle  in  which  we  are  now  engaged,  and  for  which  we  are 
preparing  to  take  such  a  prominent  part,  depends  for  its  success  as 
much  upon  the  medical  profession,  as  it  does  upon  our  combatant 
forces,  and  while  we  do  not  know  that  any  such  intention  as  herein 
suggested  is  in  the  mind  of  the  Surgeon  General,  it  would  at  least 
give  him  the  necessary  corps  of  medical  officers  upon  which  to  draw 
and  thus  serve  the  best  interests  of  our  country  and  the  best  interests 
of  the  medical  officer  serving. 


From  the  President's  Message. 


"Let  there  be  no  misunderstanding.  Our  present  and  immediate 
task  is  to  win  the  war,  and  nothing  shall  turn  us  aside  from  it  until 
it  is  accomplished.  Every  power  and  resource  we  possess,  whether 
of  men,  of  money,  or  of  material,  is  being  devoted  and  will  continue 
to  be  devoted  to  that  purpose  until  it  is  achieved.     .     .     . 


372      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

"We  shall  regard  the  war  as  won  only  when  the  German  people 
say  to  us,  through  properly  accredited  representatives,  that  they  are 
ready  to  agree  to  a  settlement  based  upon  justice  and  the  reparation 
of  the  wrongs  their  rulers  have  done.     .     .     . 

"When  this  intolerable  Thing,  this  German  power,  is,  indeed,  de- 
feated and  the  time  come  that  we  can  discuss  peace — when  the  Ger- 
man people  have  spokesmen  whose  words  we  can  believe  and  when 
those  spokesmen  are  ready  in  the  name  of  their  people  to  accept  the 
common  judgmentof  the  nations  as  to  what  shall  henceforth  be  the 
bases  of  law  and  of  covenant  for  the  life  of  the  world — we  shall  be 
willing  and  glad  to  pay  the  full  price  for  peace  and  pay  it  ungrudg- 
ingly. We  know  what  that  price  will  be.  It  will  be  full,  impartial 
justice — justice  done  at  every  point  and  to  every  nation  that  the  final 
settlement  must  affect,  our  enemies  as  well  as  our  friends." 


Bennett  Medical  College  and  the  Chicago  College  of  Medicine  and 
Surgery  are  now  combined  to  form  the  medical  department  of  Loyola 
University  of  Chicago.  The  purchase  of  the  buildings  and  equip- 
ment of  the  Chicago  College  was  made  by  Loyola  University  officials. 

Dr.  Lawrence  Ryan  is  dean  of  the  new  faculty  of  the  school;  Dr. 
Alfred  de  Roulet  is  junior  dean;  Dr.  G.  E.  Wyneken  is  secretary; 
Rev.  H.  S.  Spalding,  S.  J.,  is  regent. 

The  college  is  on  Lincoln  Street,  opposite  Cook  County  hospital, 
in  the  medical  center  of  the  west.  The  institution  comprises  five 
buildings. 

Work  will  be  carried  on  at  the  college  on  the  highest  plane  pos- 
sible to  meet  requirements  of  all  states. 

Clinical  work  at  the  school  is  taken  care  of  by  men  who  are  promi- 
nent in  the  medical  profession.  Requirements  of  the  school  for 
medical  students  call  for  one  year  of  college  work  before  entering. 


Our  Savings  and  Our  Army. 


"Our  gallant  men  in  the  field  will  do  the  fighting  with  true  Ameri- 
can valor,  but  the  responsibility  rests  upon  you  and  me  and  every 
other  citizen  of  the  United  States  who  is  not  in  active  field  service 


EDITORIALS  373 

to  provide  them  with  the  equipment  and  machines  to  enable  them  to 
fight  successfully. 

"Valor  alone  is  not  going  to  destroy  the  Kaiser  and  military  des- 
potism. We  must  have  organization  back  of  it.  Every  man  in  this 
country  must  be  a  patriot.     .     .     . 

"The  value  of  the  war-savings  plan  consists  not  alone  in  the 
amount  of  money  which  the  people  of  the  United  States  may  lend  to 
their  government  upon  the  certificates  which  are  sold,  but  also  in 
the  lesson  which  will  be  taught,  in  the  habits  of  thrift  that  will  be 
inculcated  as  a  result  of  it.  What  this  will  mean  in  conserving  the 
resources  of  America  is  inestimable.  What  this  will  mean  in  the 
future  economy  of  America  is  incalculable. 

"Victory  can  only  be  won  by  the  valor  of  our  soldiers,  combined 
with  the  intelligent  use  of  our  resources.  Savings  and  economy  en- 
large the  available  resources  of  the  country  for  war,  and  the  industry 
of  the  people  is  necessary  to  put  these  resources  in  the  form  which 
will  enable  our  soldiers  to  use  them  with  victorious  e:ect  upon  the 
battle  fronts." — From  speech  of  Secretary  McAdoo. 


War  Prices  Depriving  Babies  of  Milk. 


Washington,  D.  C,  Dec. Decreases  reported  from  New  York 

and  Chicago  and  New  England  cities  in  the  amount  of  milk  being 
consumed  by  families  with  young  children  have  led  the  Federal 
Children's  Bureau  to  emphasize  its  imperative  necessity  in  the  diet 
of  babies  and  young  children. 

Dr.  Grace  L.  Meigs,  the  Director  of  the  Bureau's  Child  Hygiene 
Division,  in  commenting  on  the  danger  of  such  a  decrease  to  the 
health  of  children  today,  said,  "Milk  is  the  one  food  that  all  young 
children  must  have  if  they  are  to  be  strong  and  healthy.  Whole 
milk  is  rich  in  the  elements  without  which  the  child's  growth  ceases 
and  his  health  is  impaired;  indeed  there  is  no  food  which  can  supply 
as  well  the  needs  of  the  growing  child. 

"There  is  no  substitute  for  milk  in  the  diet  of  babies  and  young 
children.  Yet  the  increase  in  its  price  is  so  startling  that,  as  the  re- 
ports the  Bureau  receives  show,  many  mothers  are  economizing  on 
milk.     Young  children  can  not  get  the  nourishment  they  require 


374     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 

form  the  would  be  milk  substitutes  given  them.  Patent  foods  which 
do  not  themselves  contain  milk  and  are  not  intended  to  be  mixed 
with  milk  are  so  lacking  in  the  essentials  of  health  development  that 
we  must  expect  children  fed  on  them  instead  of  on  milk  to  be  weakly 
and  ailing.  Plainly  very  great  harm  is  done  young  children  by  giv- 
ing them  tea  and  coffee  to  take  the  place  of  milk  which  is  really  a 
complete  food;  it  is  giving  them  mere  stimulants  to  replace  their 
best  food." 

Since  the  price  of  milk  went  up  to  14  cents  a  quart,  tea  and  coffee 
have  been  substituted  for  milk  by  more  than  half  of  the  2,200  fami- 
lies— all  with  children  under  six — included  in  the  study  of  the  ef- 
fect of  the  increased  price  of  milk  just  made  in  New  York  City  by 
the  Mayor's  Committee  on  Milk,  the  City  Department  of  Health  and 
the  Association  for  Improving  the  Condition  of  the  Poor.  One  hun- 
dred and  twenty  families  have  stopped  taking  milk  entirely,  in  25 
of  these  there  are  babies  under  one  year  old.  All  the  2,200  families 
have  young  children,  but  nearly  half  are  taking  from  one-fourth  to 
one-half  less  than  before  the  price  went  up.  Yet  even  before  the 
larger  price  decreased  the  amount  of  milk  they  bought  these  families 
were  getting  but  little  more  than  half  the  amount  of  milk  which  ex- 
perts on  children's  diets  say  they  need. 

In  Chicago  as  well  as  New  York  the  rise  in  the  price  of  milk  has 
forced  down  the  amount  purchased.  A  dealer  there  reports  that 
while  he  distributed  on  an  average  4,000  quarts  of  milk  a  day  in 
September,  on  October  3  with  the  price  increased,  he  distributed 
only  2,500  quarts. 

In  New  Haven,  Bridgeport  and  other  Connecticut  towns  milk  de- 
livered at  the  station  is  sold  wholesale  at  8  cents  a  quart.  It  retails 
as  high  as  15  cents  a  quart.  In  Waterbury,  when  the  price  was  raised 
from  12  to  15  cents  a  quart  the  sale  was  so  greatly  reduced  that  the 
price  has  been  dropped  back  to  14  cents. 


We  beg  to  call  the  attention  of  our  friends  to  the  statements  of 
dues  for  subscription  sent  out  with  this  issue  and  to  ask  a  reply  as 
to  whether  the  subscription  to  the  Journal  is  to  be  continued  or  not. 
Responses  will  be  highly  appreciated  as  we  wish  to  revise  the  mail- 


EDITORIALS  375 

ing  list  for  the  coming  year.    To  every  one  of  our  readers  we  extend 
our  wishes  for  a  happy  and  a  prosperous  New  Year. 


(©bttuarg 


Dr.  A.  G.  Donoho,  Sr.,  of  Hartsville,  Tenn.,  died  at  his  home  in 
that  place  November  22d,  at  the  age  of  79  years.  Thus  passed  into 
the  great  beyond  one  of  the  most  striking  figures  in  the  old  guard  of 
the  medical  profession  of  the  State.  A  veteran  of  the  civil  war,  a 
practitional  of  many  years  standing  and  a  respected  citizen  of  the 
community  in  which  he  lived,  he  went  down  to  his  death  beloved 
and  revered  by  all  who  knew  him  and  his  memory  will  always  be 
held  green  and  loving  by  all  who  came  in  contact  with  him.  His 
career  was  like  that  of  the  old  Dr.  McClure  made  famous  by  the  pen 
of  Barrie,  for  no  hardship  deterred,  no  difficulties  were  shunned  and 
no  question  of  gain  stood  in  the  way  of  doing  his  professional  duty. 
We  who  pay  this  humble  and  imperfect  tribute  knew  him  and  loved 
him. 


376      NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 


S^litehiB  nnh  Maok  Nottr^B 


Annual  Report  of  the  Surgeon  General  of  the  Public  Health  Service  of  the 
United  States.  For  the  Fiscal  Year  1916.  Washington,  Government  Printing 
Office,  1916. 

Our  thanks  are  due  the  office  of  the  Surgeon  General  for  a  copy 
of  this  exceedingly  valuable  report.  This  is  the  forty-fifth  annual 
report  of  the  service  and  covers  the  one  hundredth  and  eighteenth 
year  of  its  existence.  It  contains  a  great  deal  of  interest  to  the  prac- 
titioner, especially  the  parts  relating  to  the  investigation  of  pellagra, 
hookworm  disease,  filiarisis,  typhoid  and  typhus  fever.  The  sta- 
tistical information  contained  in  this  report  is  of  the  greatest  value. 
The  make  up  and  arrangement  is  admirable  as  are  all  work  of  this 
kind  put  forth  by  the  United  States  Government. 


PUBLISHERS'  DEPARTMENT  377 


PubltBtj^r'B  i^partm^nt 


The  Treatment  of  Epilepsy. 

In  the  treatment  of  epilepsy  the  employment  of  the  bromides  is  of  such  uni- 
versal acceptance  that  the  main  point  involved  is  the  choice  of  a  bromide  prep- 
aration that  will  subject  the  patient  to  a  minimum  of  the  evil  effects  of  the 
bromides. 

Many  physicians  have  shown  that  the  best  preparation  to  use  for  this  pur- 
pose, one  that  has  a  maximum  of  therapeutic  potency  and  productive  of  a  mini- 
mum of  the  gastric  disturbances  so  frequent  in  the  long  continued  use  of  bro- 
mides, is  BROMIDIA  (Battle).  This  superiority  of  (BROMIDIA  (Battle)  is 
due  to  the  choosing  of  pure  drugs  and  the  employment  of  the  utmost  care  and 
skill  in  compounding  it. 

BROMIDIA  (Battle)  ma>;  be  continued  for  long  periods,  a  feature  that  gives 
it  pre-eminence  in  the  treatment  of  epilepsy. 


Building  Up  After  Pneumonia. 


Every  physician  recognized  that  one  of  the  most  important  things  in  the  man- 
agement of  a  case  of  pneumonia  is  building  up  the  patient  after  the  resolution 
of  the  inflammatory  process.  For  this  purpose  Cord.  Ext.  01.  Morrhuae  Comp. 
(Hagee)  has  been  found  of  great  dependable  worth,  owing  to  the  certainty 
with  which  it  charges  the  reduced  tissue  with  the  necessary  reconstructed  ele- 
ments. It  is  a  most  rational  therapeutic  procedure  to  put  the  pneumonia  pa- 
tient on  Cord.  Ext.  01.  Morrhuae  Comp.  (Hagee)  for  by  so  doing  the  period 
of  convalescence  is  shortened  and  the  patient  is  restored  to  his  normal  vigor 
all  the  more  quickly.  The  advantage  of  using  Cord.  Ext.  01.  Morrhuae  Comp. 
(Hagee)  is  that  while  it  possesses  every  remedial  and  nutritive  quality  of  the 
plain  oil,  it  inflicts  no  burden  on  the  gastric  apparatus,  hence  it  may  be  given 
for  an  indefinite  length  of  time  without  causing  distress. 


After  an  Alboholic  Debauch. 


The  physician  is  often  called  upon  for  relief  of  the  marked  nervous  distur- 
bance following  a  prolonged  indulgence  in  alcoholic  liquors.  The  nervous  sys- 
tem is  badly  upset,  the  stomach  is  disturbed  and  the  patient  is  unable  to  per- 
form his  usual  duties.  In  the  relief  of  this  state  PASADYNE  (Daniel)  shows 
its  advantage  in  a  high  degree.  Possessing  marked  sedative  properties  it  quickly 
and  safely  secures  for  the  patient  the  rest  needed  and  restores  the  nervous  cus- 
tem  to  its  wonted  equilibrium.  It  may  be  pushed  without  fear  of  producing  a 
depressing  reaction,  and  its  therapeutic  potency  insures  accomplishment  of  the 
prime  purpose  of  its  administration. 

PASADYNE  (Daniel)  is  a  concentrated  tincture  of  passiflora  incarnata,  and 
is  a  calamative  of  the  highest  order.    It  is  of  particular  value  in  women. 

A  sample  bottle  may  be  obtained  by  addressing  the  laboratory  of  John  B. 
Daniel,  Inc.,  Atlanta,  Ga. 


378     NASHVILLE  JOURNAL  OF  MEDICINE  AND  SURGERY 
The  Great  American  Habit. 


"The  great  American  habit"  said  a  prominent  physician  a  short  time  ago, 
"is  neither  rapid  eating,  nor  dining  'too  wisely  and  well.'  These  are  evils,  to 
be  sure,  but  the  one  great  habit  to  which  most  American  are  addicted  is  the 
routine  use  of  laxatives  and  cathartics.  Is  it  any  wonder  some  European  doc- 
tor has  said  we  are  a  nation  of  constipationists!  Why,  physic  has  become 
only  a  little  less  necessary  than  the  oxygen  we  breathe." 

How  true  all  this  is,  most  physicians  of  broad  experience  will  readily  agree. 
Physic  the  first  thing  in  the  morning,  physic  before  or  after  each  meal,  and 
physic  the  last  thing  at  night!  And  only  one  purpose  throughout,  to  move  the 
bowels!     Never  a  thought  in  regard  to  regulating  them. 

This  is  the  pity  of  the  whole  situation,  for  instead  of  getting  relief  and  cor- 
recting constipation,  the  average  person  is  simply  becoming  more  and  more  a 
slave  to  the  cathartic  habit. 

To  a  certain  extent  this  is  not  surprising  for  the  great  majority  of  remedies 
are  simply  "movers'  not  "regulators." 

It  was  recognition  of  this  fact  that  led  to  the  preparation  of  Prunoids.  Here 
is  a  remdy  that  is  much  more  than  a  physic.  Used  as  the  physician's  judgment 
will  dictate,  according  to  the  needs  of  each  patient,  Prunoids  will  not  only 
move  the  bowels  satisfactorily  without  the  least  griping  or  disagreeable  effect 
but  will  so  stimulate  the  physiologic  processes  of  the  intestinal  tract  that  evac- 
uations will  become  natural  and  regular. 

It  is  the  notable  efficacy  of  Prunoids  in  correctly  intestinal  torpidity  and  re- 
storing functional  activity  of  the  bowels  that  has  led  so  many  physicians  to 
prefer  this  remedy  to  all  others  for  the  relief  and  permanent  correction  of 
chronic  constipation.  They  have  learned  that  the  use  of  Prunoids  offers  a 
means  not  alone  of  correcting  constipation,  but  what  is  especially  gratifying, 
of  curing  "the  great  American  habit." 


The  Most  Effective  Therapeutic  Remedy  for  Nervous  Diseases. 


In  the  treatment  of  many  nervous  diseases  it  not  infrequently  happens  that 
the  after-affects,  or  sequelae  of  the  remedy  are  worse  than  the  disease.  This 
statement  applies  in  particular  to  the  bromides  in  the  forms  commonly  em- 
ployed. Valuable  and  effective  as  they  are  whenever  a  sedative  or  anti-spas- 
modic is  needed,  they  must  be  prescribed  with  the  utmost  care  and  discretion, 
else  the  results,  to  put  it  mildly  may  be  unfortunate  in  the  extreme. 

The  physician  therefore,  can  not  be  too  critical  and  cautious  in  selecting  the 
preparation  of  the  bromides  he  uses,  especially  if  it  must  be  given  for  any 
considerable  period.  Many  men  know  the  advantages  of  Peacock's  Bromides 
but  to  those  who  do  not  it  should  be  pointed  out  that  this  high  grade  product 
easily  stands  at  the  head  of  available  bromide  preparations  not  only  in  free- 
dom from  objectionable  effects  but  also  in  therapeutic  efficiency. 

Extended  clinical  experience  has  shown  that  owing  to  the  purity  and  quality 
of  the  constituent  salts,  this  combination  does  not  upset  the  organs  of  diges- 
tion nor  give  rise  to  the  highly  disagreeable  condition  known  as  bromism. 

Physicians  who  use  Peacock's  Bromides  know  the  satisfaction  of  accomplish- 
ing not  only  the  results  they  seek,  but  without  creating  any  disagreeable  and 
annoying  conditions  which  call  for  explanation  and  excuse. 


Vol.  CXI 


JANUARY,  1917 


Number  I 


NASHVILLE  JOURNAL 


OF': 


MEDICINE  AND  SURGERY 

Established  1851 

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


PUBLISHED  MONTHLY     -      -     $1.00  a  Year  in  Advance 


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LVU5IZESI- 

For  Convenience  in  prescribing 


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ORIGINAL  COMMUNICATIONS 

Is  Prohibition  a  Practical  Medico-Legal  Question 1 

EXTRACTS  FROM    HOME  AND  FOREIGN  JOURNALS 
Surgical 

The  French  Treatment  of  Burns G 

Is  the  Gall  Bladder  Useless 7 

Is  Laudable  Pus  Laudable 7 

The  Treatment  of  Hemorrhoids  by  a  New  Method S 

Fractures  About  the  Wrist  in  Childhood  and  Adolescence 9 

Treatment  of  Boils    (Furunculosis) 9 

The  Hand  Sign  in  Syphilis In 

Medical 

Coddling  of  Children  and  the  Infectiousness  of  Colds 11 

The  Pharmacology  of  Emetine 12 

To  Relieve  Pain  in  Incipient  Alveolar  Abscess  or  in  Neuralgia.  ...  12 

A  Cure  for  Enuresis 13 

Myocardial  Efficiency    1?, 

The  Faucial  Tonsils  in  Singers 14 

Subcutaneous  Administration  of  Fresh  Human  Blood 14 

Preventive  Sun  Cure 15 

Obstetrical 

Pituitary  Extract  in  Obstetrical  Practice IG 

The  High  Forceps  Application 17 

Operation  for  Retro  Displacements  of  the  Uterus 17 

Biologic  Diagnosis  of  Pregnancy IS 

Nonprotein  Nitrogen  and  Urea  in  Maternal  and  Fetal  Blood 18 

Pregnancy  Toxemia    19 

Toxemia  of  Pregnancy 20 

EDITORIAL 21 

BOOK  NOTICES   28 

PlTBLISHERS     30 


BRONCHIAL  COUGHS 

and  other  respiratory  affections  so  often  owe   their  intractability  to 

malnutrition  and  debility  that  vigorous  tonic  medication  always 

forms  one  of  the  first  and  most  important  indications  for  their 

treatment.     The  results  that  uniformly  follow  the  use  of 

Gray's  Gly  cerine  Tonic  Comp. 

in  this  class  of  affections,  prove  the  wisdom,  therefore,  of  ''treating 
the  patient  as  well  as  the  disease."  The  exceptional  efficiency  of  this 
time-tried  tonic  in  all  diseases  of  the  air.  passages  has  led  to  its 
widespread  recognition  as  one  of  the  general  practitioner's  most  de- 
pendable allies  in  his  annual  conflict  with  winter  coughs  and  colds. 

Its  results  moreo'vcr,  are  permanent — not  transitory. 
THE  PURDUE  FREDERICK  CO.,  298  Broadway,  New  York. 


The  Briggs  Infirmary 

FOR  THE  TREATMENT  OF  SURGICAL  DISEASES 


THIS  INSTITUTION  is  located  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 
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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-Sixth 
season  opens  September  10,  1916.     For  further  information  address — 


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


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